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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202351
Report Date: 01/05/2026
Date Signed: 01/05/2026 10:39:31 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2023 and conducted by Evaluator Audrey Jeung
COMPLAINT CONTROL NUMBER: 26-AS-20230914081638
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: 108DATE:
01/05/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tyler ManzoTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff left resident in urine and feces for extended periods of time.

- Staff are not repositioning resident resulting in worsening wounds.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Based on review of facility and home health care records and interviews with staff and witness, these allegations are determined to be unsubstantiated.
Client #1 was admitted on 2/16/16 and was hospitalized on 9/14/23 for care and treatment of pressure injuries of buttocks, ankle and foot.
Client was discharged from home health care on 9/7/23 because stage II pressure injuries of buttocks were responding well to wound care and healing. Stage I pressure injuries of ankle and foot were essentially closed and healed. Facility staff were provided detailed instructions for ongoing wound care by home health nurse on 9/7/23 upon home health discharge. Pressure injuries were observed and evaluated on 9/12/23 by home health nurse, necessitating resumption of home health nursing care for decubitus ulcers of ankle--stage III or IV--foot--stage I or unstageable--and buttocks--stage II.
There was no evidence that the pressure wounds worsened because staff neglected to reposition client every 2 hours, nor that staff failed to change client's diapers and allow client to remain in soiled diapers for an extended period of time.

Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cowan April
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026
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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