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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202351
Report Date: 08/01/2024
Date Signed: 08/01/2024 12:43:05 PM


Document Has Been Signed on 08/01/2024 12:43 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: 111DATE:
08/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Dana MalengoTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Director of Resident Care Services, Dana Malengo.

The purpose of the visit is to address incident reports and death reports that are submitted late to the Department from April 1, 2024 – July 25, 2024.

The facility file for incident reports was reviewed. Based on review, between April 1, 2024 – July 25, 2024, the facility submitted 15 late incident reports and 4 late death reports to the Department. The incident reports and death reports were reported more than 7 days after the occurrence date.

Based on interview, the Executive Director is the only person who is submitting the incident reports and/or death reports to Licensing. The ED states the incident reports and death reports are sometimes late when ED is not in the community. By the time the ED returns to the community is when the incident reports are submitted to Licensing. ED states a plan to ensure incidents and death reports are submitted within Title 22 reporting requirements.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Resident Care Services, Dana Malengo and a copy of the report and appeal right were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
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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Document Has Been Signed on 08/01/2024 12:43 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: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2024
Section Cited
CCR
87211(a)(1)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. ... This requirement is not met as evidenced by:
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Licensee will work out a plan to ensure incidents are submitted within reporting requirements. Licensee will submit a statement of understanding of the section cited, to LPA Dolores via email by POC due date.
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Based on interview, record review, and observation the licensee did not ensure to report incidents and death reports to the Department within 7 days of the occurrence which poses a potential health, safety, and personal rights risk to persons in care.
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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: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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