435202350-9-27-2023-26-AS-KHOS-CW8H9A-20231002055938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202350
Report Date: 09/25/2023
Date Signed: 09/27/2023 08:10:06 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/12/2021 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210812151804

FACILITY NAME:	BELMONT VILLAGE SAN JOSE		FACILITY NUMBER:	435202350
ADMINISTRATOR:	GILDA DEOCARES		FACILITY TYPE:	740
ADDRESS:	500 S WINCHESTER BLVD		TELEPHONE:	(408) 984-4767
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	150	CENSUS: 110	DATE:	09/25/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Gilda Deocares		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility not being cleaned adequately.
Facility did not communicate with authorized representative about leaving facility.
Residents not wearing mask on outing.

INVESTIGATION FINDINGS:

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On 09/25/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Director of Resident Care Services, Gilda Deocares and explained the purpose of today's visit.

Regarding the allegation that facility is not being cleaned adequately, Reporting Party (RP) mentioned that the resident's (R1) room was dusty, dirty toilet and mold in sink.

Based on interviews, housekeeping are done once a week in residents room. There are occassions where residents or family member request the room to be cleaned due to accidents or incidents and facility addresses these requests promptly. Aside from weekly housekeeping, constant checks are done in rooms and trash is being emptied accordingly.

LPA toured the room and it didn's show any molds. Bathroom is clean and all of the residents belongings are intact.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210812151804

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: BELMONT VILLAGE SAN JOSE	FACILITY NUMBER: 435202350
	VISIT DATE: 09/25/2023

NARRATIVE

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Regarding the allegation that facility did not communicate with authorized representative about leaving facility, RP stated that there was no advice from facility that there will be an outing for R1.

Based on interviews, residents are presented with different activities. They are to decide if they want to join said activities or not. Residents who join these facility activity are able to make decisions for themselves. No prior authorization needed from family members unless stated otherwise. Since residents are able to decide for themselves, if they wanted to attend and a family member doesn't want them too, the facility will follow the residents decision because it is residents their right.

Regarding the allegation of residents not wearing mask on outing, RP saw photo of an event showing R1 wearing mask underneath his/her nose.

LPA reviewed facility's COVID protocols during this time and it stated there that only fully vaccinated visitors are allowed to attend the event, and that proof of vaccine documentation is required. All residents and visitors must wear surgical masks during any visit. While masking during this time is a must, it is not required. And during an event where residents play or exert some effort, masks might fall. Facility still tries to encourage residents to wear the mask.

Based on interview, staff mentioned that everyone in the event has been verified to have been vaccinated and temperature checks were done. There were no reports where any one of the attendees got COVID during this event.

Therefore, based on the interviews conducted, files reviewed, and information collected, the allegations mentioned are UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed and a copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC9099 (FAS) - (06/04)

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