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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202350
Report Date: 12/09/2020
Date Signed: 12/17/2020 10:34:58 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: 98DATE:
12/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Natalie BarmanTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Karen Taku and Program Clinical Consultant Clarita DelaCruz conducted a virtual tele-visit via ZOOM, to provide technical assistance to prevent and mitigate the spread of COVID-19 within the facility. LPA met with Executive Director (ED) Natalie Barman and Administrator Gilda Deocares.

During today's tele-visit, the following recommendations were made to the facility:

1. Post hand washing signs in each residents room

2. Staff PPE training should include the demonstration of donning and doffing of PPE

The report was reviewed the Executive Director, and a copy was provided via email for signature.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
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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