435202350-4-16-2025-26-AS-MMOR-DFSNMW-20250416103550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202350
Report Date: 04/16/2025
Date Signed: 04/16/2025 10:36:03 AM

Document Has Been Signed on 04/16/2025 10:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	BELMONT VILLAGE SAN JOSE		FACILITY NUMBER:	435202350
ADMINISTRATOR/ DIRECTOR:	RACHEL BROWN		FACILITY TYPE:	740
ADDRESS:	500 S WINCHESTER BLVD		TELEPHONE:	(408) 984-4767
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY: 150	TOTAL ENROLLED CHILDREN: 0	CENSUS: 116	DATE:	04/16/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Administrator Rachel		TIME VISIT/ INSPECTION COMPLETED:	10:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On April 16, 2025, Licensing Program Analyst Manuel Monter conducted a case Management Incident visit regarding an incident report the Department received, stating there was a water leak at the facility. On April 15, 2025, the Department received an incident report that stated, " On 04/13/25 around 10:59 AM, a leak was observed in the elevators. Staff alerted ... Executive Director, Rachel Brown. Elevators stopped on the nearest floor and opened, and were shut down. A plumber, elevator technician, and two water removal/remediation crews were brought on site. The source of the leak was found to be a water holding tank for the boiler, located on the roof. Water flooded into laundry rooms on floors 2-7 and traveled from laundry rooms into elevator doors and 11 resident apartments total, across floors 2-7. Water also impacted the 1st Floor lobby.... Executive Director, who called vendors for urgent assistance. LVN on Duty turned off main water. Vendors stopped flooding, removed water, and worked on drying wet surfaces. Elevator tech assessed elevator operations. Executive Director informed all responsible parties via email and called responsible parties of impacted apartments. Staff transported residents who were in programs back to their apartments via stairs, as directed by LVN on Duty. After removing water, remedial on crews placed fans & dehumidifiers in affected common areas and apartments on 4/13125,Remediation crews will check progress daily until areas are dry" Page 1 Out of 2.

Romeo Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 04/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE SAN JOSE	FACILITY NUMBER: 435202350
	VISIT DATE: 04/16/2025

NARRATIVE

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On April 16, 2025, Licensing Program Analyst Manuel Monter toured the facility 1-7 floors. LPA observed the areas that were affected by the water leak, which was areas directly next to the laundry rooms on floors 2-7. This water that leaked, traveled from laundry rooms into elevator doors and 11 resident apartments total, across floors 2-7. During the tour, LPA observed fans and dehumidifiers in each floor, and noted there was no smell or current sign of wetness during the tour.

LPA interviewed facility Administrator. ADM stated 3 residents who were residing near the area, where the water leaked, moved to different apartments. ADM stated she has been talking to the residents to ensure they are doing well. ADM stated no resident was physically impacted by the water leak. ADM stated the Fans and dehumidifiers will continue to run until the moisture is gone, but stated vendors estimate the completion date by Friday. ADM also stated the water leak effected the elevators control panels. ADM stated the elevators still work, but need to operate manually. ADM stated the control panels for the elevator have been ordered and should arrive at the facility by Saturday, and installed by this Sunday. ADM stated the facility is assisting residents go down the to first floor by; the facility will manually operate the elevator, via the key and will escort residents down. ADM stated because the panels on the elevator are not functioning, they need to use a key to manually operate it.

ADM stated her plan of action to address the leak and wet areas is the facility will be evaluating the tank. ADM stated they will assess the tank to see if they can reinforce the tank, as a temporary measure to ensure a leak does not re occur in the short term. ADM stated the facility is planing on replacing both hot water tanks.

ADM stated her plan of action to ensure the health and safety of residents in care, is to continue to deliver meals. ADM stated once the elevator panel is fixed sometime this weekend, dinning can open for residents in the weekend. ADM stated she is staying in contact with the residents, asking how they are doing and family's to keep them updated on the ongoing process.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report was provided.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025

LIC809 (FAS) - (06/04)

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