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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202350
Report Date: 02/05/2025
Date Signed: 02/05/2025 01:39:31 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20240304153845
FACILITY NAME:BELMONT VILLAGE SAN JOSEFACILITY NUMBER:
435202350
ADMINISTRATOR:RACHEL KELLYFACILITY TYPE:
740
ADDRESS:500 S WINCHESTER BLVDTELEPHONE:
(408) 984-4767
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:150CENSUS: 117DATE:
02/05/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Executive director - Rachel BrownTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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- Facility does not respond to emergency pull cord signals in a timely manner.
- Facility not providing medications to resident when requested
- Facility is not providing contracted services
- Facility is not changing resident's urine bag
INVESTIGATION FINDINGS:
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On 02/05/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver the findings regarding the recieved allegations. LPA met with executive director Rachel Brown and explained the purpose of today's visit.

During the course of the investigation interviews were conducted, observations were made, and documents were received. Call logs show a pattern of responsiveness that were best met by time and staff on hand to be resonable depending on the service needed. Medication records observed and interviews show that all prescribed medications were given as prescribed and directed, this would include the changing of the resident's urine bag. When alerted staff would respond based on the demand of staffing and business of the facility. Staff are not informed of the type of service needed when called upon but do respond based on the records reviewed. The resident did not have one on one caregiving. All services were met by the facility to the best of their abilities at the time. These allegations are unsubstantiated based on the totality of observations made and investigation conducted.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Rachel Brown and a copy is provided on this day.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
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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