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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202350
Report Date: 05/31/2024
Date Signed: 05/31/2024 03:37:08 PM


Document Has Been Signed on 05/31/2024 03:37 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:BELMONT VILLAGE SAN JOSEFACILITY NUMBER:
435202350
ADMINISTRATOR:RACHEL BROWNFACILITY TYPE:
740
ADDRESS:500 S WINCHESTER BLVDTELEPHONE:
(408) 984-4767
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:150CENSUS: 103DATE:
05/31/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rachel BrownTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with Executive Director (ED) Rachel Brown.

On 05/30/2024, the Department was notified of a serious incident that occurred with resident (R1) and staff (S1). On 05/29/2024 around 9PM, the facility received an alert from their fall detection system from R1's bedroom. The review of the video showed a staff (S1) assisting R1 back to bed in a rough manner. The Executive Director was notified of the incident immediately and S1 was escorted out of the building. Staff was immediately suspended and did not return to work after the incident.

After the incident, staff assessed R1 and observed redness on R1's left cheek and scratches on the forehead. Emergency services were not contacted as R1 did not complain of any unusual pain. The facility notified R1's family, Ombudsman, and local law enforcement. On 05/30/2024, in-service training was conducted with staff to include the topics of elder abuse, mandated reporting, and R1's care plan.

During visit, LPA interviewed 2 staff members and R1. LPA reviewed the video with ED and recorded part of the video using LPA's state issued cellular device. LPA requested the video footage from the facility's fall detection system to be sent via email.

Documents were obtained to include the law enforcement case number, in-service training records, and S1's personnel file. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
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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