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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202351
Report Date: 12/08/2020
Date Signed: 01/04/2021 11:24:35 AM

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 SUNNYVALEFACILITY NUMBER:
435202351
ADMINISTRATOR:SINGH, RADHIKAFACILITY TYPE:
740
ADDRESS:1039 E EL CAMINO REALTELEPHONE:
(408) 720-8498
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:150CENSUS: 120DATE:
12/08/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Lola BullockTIME COMPLETED:
10:22 AM
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Due to COVID-19 pandemic, Licensing Program Analysts (LPAs) Yatfai Eric Ng and Jackie Jin, partnered with a Nurse Evaluator II (NE) Kathleen Weiss from the Department, conducted a Case Management - Other - tele-visit via FaceTime, to provide a technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPAs and NE met with the Assistant Executive Director (AED) Lola Bullock.

LPAs and NE toured the facility virtually with AED holding the telephone to show around the facility. Staff were observed in the facility wore masks. Hand sanitizing stations were scattered around the facility. COVID-19 signage were visible throughout the facility. There were soap, paper towels, COVID-19 signage available in the restrooms in the common area. Dining room was closed. Residents had their meals in their rooms. Break room and the break area outside of the facility for staff had a maximum capacity of 4 in each respectively. They both had adequate space to accommodate 4 staff with enough area to practice social distancing.

A staff demonstrated donning personal protective equipment (PPE) before entering the COVID-19 positive resident's room in memory care unit. There was a covered trash bin for the used PPE inside the isolation room.

During the tour in assisted living unit, AED was advised to put a covered trash bin inside of the isolation room for PPE disposal. This was for mitigation and infection control practices to prevent, contain, and mitigate the spread of COVID-19. AED immediately obtained one for that particular room.

No other issues observed during tour. No deficiency cited during tour.

This report was sent to AED to review and to obtain a signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2020
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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