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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202350
Report Date: 02/10/2023
Date Signed: 02/10/2023 02:55:41 PM


Document Has Been Signed on 02/10/2023 02:55 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:
02/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Gilda DeocaresTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with Director of Resident Care Services (DRCS), Gilda Deocares. LPA explained the purpose of the visit was to obtain additional information from an indent report we received for resident (R1).

During today's visit, 1 staff member was interviewed. LPA also toured parts of the facility with DRCS to include the front desk, first floor, sixth floor, and exit areas.

On 02/06/2023, the Department received an incident report that occurred on 02/05/2023 regarding a resident who eloped from the facility. R1 was found by a police officer and was transported to the hospital for evaluation. No injuries were noted and the resident returned to the community on the same day.

The Department received requested documents to include R1's physician's report, assessment and service plans, and training records. Based on record review, R1 is not able to leave the facility unassisted.

On 02/06/2023, the facility took proper steps to ensure R1's safety to include contacting the appropriate parties, conducting a re-assessment and evaluation, inspecting the facility grounds, and providing an in-service training to all staff on elopement.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with DRCS, 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: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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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