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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202350
Report Date: 06/28/2022
Date Signed: 06/28/2022 10:59:02 AM


Document Has Been Signed on 06/28/2022 10:59 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
CCLD Regional Office, 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: 97DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Natalie BarmanTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Executive Director (ED), Natalie Barman.

During visit, LPA toured the facility with the ED to include floors one through seven. Facility has a designated symptom screening area and temperature check (Accushield) for all visitors and residents. LPA observed the staff symptom screening area and temperature check located on the first floor. Hand sanitizer available upon entry and throughout facility.

LPA observed the restrooms contained hygiene products and paper supplies. LPA advised to place a 20 second hand washing sign in all the common area restrooms. Facility has a sufficient amount of PPE carts to include posters of donning and doffing, contact precaution, and droplet precaution. LPA observed facility's PPE supplies and Antigen test kits. Trash cans observed with a lid. Facility staff clean and disinfects multiple times daily and as needed. Staff are trained annually and as needed on infection control. All staff are N95 fit tested. The following poster was observed throughout the facility to encourage hand washing, cover your cough, social distancing, and symptoms of COVID.

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

This report was reviewed with the Executive Director and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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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