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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202350
Report Date: 06/22/2023
Date Signed: 06/22/2023 11:58:50 AM


Document Has Been Signed on 06/22/2023 11:58 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 JOSEFACILITY NUMBER:
435202350
ADMINISTRATOR:NATALIE BARMANFACILITY TYPE:
740
ADDRESS:500 S WINCHESTER BLVDTELEPHONE:
(408) 984-4767
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:150CENSUS: 103DATE:
06/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Gilda DeocaresTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident vist. LPA met with Director of Resident Care Services (DRCS), Gilda Deocares. On 06/07/2023, the Department received a SOC-341 regarding an incident reported on 06/05/2023. It was alleged resident (R1) was taken out of meetings and was molested by a suspected abuser (SA). The reporting party was another resident (R2).

On 06/05/2023, the facility conducted an internal investigation after being made aware of the incident. The SA is a contracted staff at the facility who provides services in the facility’s fitness center. SA was immediately requested to not perform any services to any residents until the investigation is complete. Facility’s nurse conducted a visual assessment on R1 who seemed to be in good spirits with no emotional distress noted. The Executive Director and Director of Resident Care Services interviewed about 7 residents who did not report any inappropriate and/or suspicious behavior. 5 out of 7 residents interviewed also participate in 1:1 exercises with SA. 2 out of 7 residents interviewed participate in the same program as R1. On 06/06/2023, R1’s family visited R1 and did not report any unusual behaviors.

During today's visit, LPA interviewed 7 residents and 1 family member. Based on interviews, there was no signs and report on any inappropriate behavior between any staff members and residents. 7 out of 7 residents stated they are well treated at the facility. Based on interview with the DRCD, SA has returned to the facility and provides services for the residents at the fitness center. On 06/07/2023, facility conducted an in-service training with staff on mandated reporting. Documents were reviewed and obtained to include resident roster, staff roster, staff in-service training, and resident (R2)’s physician’s report and services plan.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Director of Resident Care Services (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: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
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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