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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202350
Report Date: 06/29/2021
Date Signed: 07/01/2021 09:20:05 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: 94DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Natalie BarmanTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Karen Taku conducted an unannounced Infection Control site visit. LPA met with Executive Director (ED) Natalie Barman.

LPA toured the facility with the ED. LPA observed a designated entry point for universal symptom screening (Accushield), including temperature check, PPE, and a touchless hand sanitizer station. LPA observed staff conducting C-19 screening for visitors and residents returning to the community. Hand sanitizer stations and COVID-19 prevention posters were observed on each floor in the facility. Restrooms were observed with hand washing posters, soap, paper towels, and a touchless trash can. LPA observed all staff wearing face masks. LPA observed an adequate supply of PPE. Common areas were observed adequately furnished, well-lit, and in good repair. Hallways were observed to be well-lit and free of obstruction.

The facility will continue with surveillance testing for staff that aren't fully vaccinated.

LPA requested an updated copy of the following documents:

1. LIC 500- Personnel Summary
2. LIC 308- Designation of Administrative Responsibility
3. LIC 610- Emergency Disaster Plan
4. Current Administrator's Certificate

No deficiencies cited during today's visit. This report was reviewed with the ED and a copy was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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