435202350-9-22-2023-26-AS-KHOS-CW8H9B-20231002055938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202350
Report Date: 09/19/2023
Date Signed: 09/22/2023 06:23:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/12/2021 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210812151804

FACILITY NAME:	BELMONT VILLAGE SAN JOSE		FACILITY NUMBER:	435202350
ADMINISTRATOR:	GILDA DEOCARES		FACILITY TYPE:	740
ADDRESS:	500 S WINCHESTER BLVD		TELEPHONE:	(408) 984-4767
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	150	CENSUS: 110	DATE:	09/19/2023
		ANNOUNCED	TIME BEGAN:	01:39 PM
MET WITH:	Allyson Fujii		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Resident not being provided adequate food service.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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On 09/19/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Memory Program Coordinator, Allyson Fujii and explained the purpose of today's visit.

Regarding the allegation of resident not being provided adequate food service, it was reported that resident (R1) was only provided grilled cheese.

Based on interviews and record reviews, R1 likes to eat sandwiches and salads. A caregiver (S1) stated that R1 loves eating salads. As for sandwiches, R1 likes grilled cheese or peanut butter and jelly. While R1 may have specific preference on what to eat, suggestions and options are also given to them. Facility menus have extensive choices for residents. R1 also has an option on what she/he wants to eat.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210812151804

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: BELMONT VILLAGE SAN JOSE	FACILITY NUMBER: 435202350
	VISIT DATE: 09/19/2023

NARRATIVE

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Regarding the allegation that facility is in disrepair, it was reported that locks don’t work, and door would not close properly.

Based on interview, record review and observations, LPA visited the room of the R1 and observed that the door lock is fixed and closes properly. All belongings of R1 are intact.

Therefore, based on the interviews conducted, files reviewed, and information collected, the allegations that resident not being provided adequate food service and facility is in disrepair are UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed and a copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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