435202351-5-27-2025-26-AS-KJAN-DH3VMW-20250527163413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202351
Report Date: 05/27/2025
Date Signed: 05/27/2025 04:34:56 PM

Document Has Been Signed on 05/27/2025 04:34 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 SUNNYVALE		FACILITY NUMBER:	435202351
ADMINISTRATOR/ DIRECTOR:	RADHIKA SINGH		FACILITY TYPE:	740
ADDRESS:	1039 E EL CAMINO REAL		TELEPHONE:	(408) 720-8498
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY: 150		CENSUS: 111	DATE:	05/27/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	04:00 PM
MET WITH:	Tyler Manzo		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

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On May 27, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident inspection visit regarding a self-reported SOC 341 for the financial abuse incident. Upon arrival, the LPA was greeted by the Executive Director (ED), Tyler Manzo. The LPA disclosed the purpose of the visit. ED stated that on May 21, 2025, at approximately 11:00 AM, the daughter of resident R1 contacted the facility to report that R1 had been writing checks to their caregiver, staff member S1, at Belmont Village Sunnyvale. The family member (FM) provided copies of six (6) cashed checks dating back to August 26, 2024, totaling $6,850. R1 was his own financial power of attorney and resided in the Assisted Living unit of the community. S1 did not and would not have access to R1.

The ED reported reviewing evidence showing that six checks were endorsed on the back and cashed by the facility employee, S1. As a result, S1 was terminated over the phone. The ED noted that there had been no prior concerns or complaints involving S1. The ED confirmed that the facility has a policy prohibiting employees from accepting gifts from residents or their family members. In cases where residents or families insist on giving a gift, the policy requires the employee to report it to the ED, who then contacts the power of attorney (POA) to determine proper handling.

The ED further stated that on May 23, 2025, S1 returned to the facility and returned $5,000 in cash from the total $6,850 received from R1. S1 reportedly lacked the funds to return the remaining $1,850. The ED met with R1 and the FM at 2:30 PM to hand over the $5,000 returned by S1. The ED confirmed that S1 remained terminated from employment and that the partial repayment did not affect the termination decision.

LPA conducted a wellness check on R1 by visiting their room. R1 stated that they were doing good and it was their judgement to write checks to S1, and no one forced R1 to write checks.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 05/27/2025

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R1 mentioned that they recently gave one check to S1 in the amount of $5000. Prior to that R1 had given checks in the amount of about $2000 as S1 was not paid when S1 was sick or taking care of their family. R1 stated that S1 never demanded any money and it was R1's impression that S1 needed help. R1 further stated that they still worry about S1 as it was their fault and hope the licensing department is not too tough on S1.

LPA requested and received the following documents from the ED:

1) R1's admission agreement 2) R1's care plan 3) R1's LIC 602 Physician’s Report

4) Copies of the 6 checks (front and back) 5) Facility's Work Rules

6) Notes on the facility’s investigation and corrective action 7) S1's employee file

8) Staff schedule for the months when the checks were given

No deficiencies were cited during today's visit.

An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Tyler Manzo, whose signature on this form confirms receipt of the report.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

LIC809 (FAS) - (06/04)

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