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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202350
Report Date: 01/26/2023
Date Signed: 01/26/2023 02:59:23 PM


Document Has Been Signed on 01/26/2023 02:59 PM - 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 JOSEFACILITY NUMBER:
435202350
ADMINISTRATOR:NATALIE BARMANFACILITY TYPE:
740
ADDRESS:500 S WINCHESTER BLVDTELEPHONE:
(408) 984-4767
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:150CENSUS: DATE:
01/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Gilda DeocaresTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived at the facility unannounced to conduct a Case Management - Other visit and met with Director of Resident Care Services, Gilda Deocares.

The purpose of the visit was to deliver an immediate exclusion letter to exclude an employee (S1) associated to the facility.

The immediate exclusion letter was handed to the Director of Resident Care Services during today's visit.

LPA advised the facility to go through their facility roster on Guardian and to disassociate individuals who are no longer employed at the facility.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Director of Resident Care Services, Gilda Deocares and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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