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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202350
Report Date: 09/16/2020
Date Signed: 09/18/2020 08:03:34 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BELMONT VILLAGE SAN JOSEFACILITY NUMBER:
435202350
ADMINISTRATOR:GILDA DEOCARESFACILITY TYPE:
740
ADDRESS:500 S WINCHESTER BLVDTELEPHONE:
(408) 984-4767
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:150CENSUS: 96DATE:
09/16/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:24 PM
MET WITH:Gilda Deocares and Rhadika SinghTIME COMPLETED:
05:45 PM
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Licensing Program Analysts(LPA's) Grace Davis, Steve Chang and LPM Romeo Manzano, conducted an unannounced Tele- Inspection -Case Management Visit via face time. Due to COVID-19 preventive measures, facility visits have been suspended. LPA's met with Administrator/Director of Resident Care Services (ADM) Gilda Deocares and Rhadika Singh, Executive Director (ED).

LPAs informed the purpose of visit to ensure that the facility is adhering to COVID-19 protocols like CDC, LPH and CCLD. LPAs toured the facility's Memory Care Units (second and third floor). Residents and staff were observed on both floors. Staff were observed maintaining social distancing with providing snacks. Also, staff (direct care, medication technician and licensed medical professionals) were observed wearing PPEs like face shield and face mask.

According to ED and ADM, medication technician and licensed medical professionals wears KN95 while direct care staff wears surgical mask. There were 7 direct care staff observed and greeted during visit. ED and ADM stated that the facility had a mass testing on 9/11/2020 with no new cases positive of COVID-19 and will continue another round of mass testing then thereafter, the facility will do 10% surveillance testing. ED stated that the Santa Clara County PH is contacted daily and on 9/15/2020, the Santa Clara Public Health nurse visited the facility and no concerns.

ADM stated that Santa Clara PH recommended that the facility staff to use N95 when providing care to positive COVID-19 residents and PUIs. ED stated that the facility has plenty of PPE supplies but needs N95 wherein they requested from Santa Clara County but it will take some time from them to provide. CCLD will provide 200 pieces of N95 before the end of the week.

Exit Interview was conducted with Administrator Gilda Deocares. No deficiency cited during today's Tele Inspection.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Grace DavisTELEPHONE: (408) 314-5102
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020
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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