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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202350
Report Date: 06/26/2024
Date Signed: 06/26/2024 04:48:42 PM


Document Has Been Signed on 06/26/2024 04:48 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
Lookup Error,
, CA



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: 104DATE:
06/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rachel BrownTIME COMPLETED:
05:15 PM
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On 6/26/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator, Rachel Brown. LPA explained the purpose of the visit.

LPA & LPM toured the facility inside and a random sample of resident rooms, common areas, and kitchen area. LPA observed some residents were at different activity rooms. While touring the facility it was observed that the temperature was at 74 deg F. Hot water was also tested in the resident rooms and the temperature was at 112 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. Resident call buttons were checked and functioning except for one random room that was checked. It was fixed right away. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are done every month.

Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA interviewed four residents and four staff.

LPA received the following documents, Certificate of Liability Insurance & LIC500.

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
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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