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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202351
Report Date: 04/26/2024
Date Signed: 04/26/2024 04:43:45 PM


Document Has Been Signed on 04/26/2024 04:43 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 SUNNYVALEFACILITY NUMBER:
435202351
ADMINISTRATOR:LOLA BULLOCKFACILITY TYPE:
740
ADDRESS:1039 E EL CAMINO REALTELEPHONE:
(408) 720-8498
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:150CENSUS: 120DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:LOLA BULLOCKTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility annual required 1 - year inspection. LPA met with Executive Director (ED) Lola Bullock.

LPA toured the facility inside and outside with ED to include the independent living, assisted living, and memory care unit. All fire exit routes were free and clear of obstruction. Stairwell observed to include an evacuation chair. Elevator in working condition. Activities calendar posted throughout the facility in the independent / assisted living unit and memory care unit. LPA observed residents participating in various activities throughout the day. Facility temperature maintained between 71 - 72 degrees Fahrenheit. Fire extinguisher was last services in July 2023. Facility has a carbon monoxide detector present.

With the assistance of the ED, LPA entered into rooms #426, #402, #309, #326, #238, #243, #220, #206, #102, and #105. 10 out of 10 apartments observed with a bed, clean linens, adequate lighting, night-stand, chair, and dresser. Bathrooms observed with grab bars and non-slip mats. Hot water temperature in RM #426, #309, #243, and #102 maintained between 106 - 120 degrees Fahrenheit. Medication carts observed locked. LPA observed chemicals, disinfectants, sharp objects, and medications observed locked in memory care.

Facility kitchen observed clean and well maintained. Refrigerator temperature maintained at 38 degrees Fahrenheit and freezer temperature maintained at 0 degrees Fahrenheit. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Food items in the refrigerator observed covered. Dining room equipped with utensils, plates, cups, and napkins.

SEE LIC809-C.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SUNNYVALE
FACILITY NUMBER: 435202351
VISIT DATE: 04/26/2024
NARRATIVE
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LPA reviewed 11 resident files. 11 out of 11 resident files observed maintained to include an updated medical assessment, TB result, updated needs and services plan, identification emergency information, admission agreement, consent forms, and personal rights. 3 out of 4 resident files contained a physician's order for a postural support. ED was advised regarding 1 out of 4 residents. 11 residents centrally stored medications and centrally stored medication records were reviewed. LPA observed multiple PRN medications for 5 out of 11 residents were not recorded in the centrally stored medication record binder. The medications that were not part of the centrally stored medication record binders were filled in 2023. Staff stated the CSMR is now archived in the facility's attic, however, the medication is documented in their Electronic - Medication Administration Record. ED was advised.

LPA reviewed 6 staff files to include a 1st aid certification, health screening, TB result, personnel record, fingerprint clearance, and training records. LPA was unable to review 1 out of 6 staff health screening and TB result. 2 out of 6 staff files observed contained a 1st aid certification. 6 out of 6 staff are fingerprint cleared. LPA did not observed 2 out of 6 staff members received at least 20 hours of annual training to include topics to include but not limited to dementia, postural supports, restricted health conditions, and hospice care.

Facility has an emergency disaster plan. Emergency drills are being conducted quarterly. LPA reviewed the infection control plan and infection control training.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Advisory notes provided. This report was reviewed with Executive Director, Lola Bullock and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/26/2024 04:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SUNNYVALE
FACILITY NUMBER: 435202351

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in 5 out of 11 counts wherein 5 residents PRN medications were not properly documented in the centrally stored medication record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee will submit a statement of understanding of the section cited above and the 5 residents centrally stored medication records to LPA Dolores via email POC due date.
Type B
Section Cited
CCR
87411(f)
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in 1 out of 6 counts wherein LPA was unable to review a staff member's health screeing and TB result which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee will submit a statement of understanding of the section cited above and the staff member's health screening report to LPA Dolores via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/26/2024 04:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SUNNYVALE
FACILITY NUMBER: 435202351

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in 2 out of 6 counts wherein LPA did not observed 2 staff members file contained at least 20 hours of annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee will submit a statement of understanding of the section cited above and a written plan to ensure staff will be up to date with training to LPA Dolores via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4