435202351-1-14-2026-26-AS-BCHN-DR5Q4Z-20260209105106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202351
Report Date: 01/14/2026
Date Signed: 01/14/2026 02:46:47 PM

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
10/27/2025 and conducted by Evaluator Yi Sam Jian

COMPLAINT CONTROL NUMBER: 26-AS-20251027221630

FACILITY NAME:	BELMONT VILLAGE SUNNYVALE		FACILITY NUMBER:	435202351
ADMINISTRATOR:	MANZO, TYLER J		FACILITY TYPE:	740
ADDRESS:	1039 E EL CAMINO REAL		TELEPHONE:	(408) 720-8498
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	150	CENSUS: 110	DATE:	01/14/2026
		UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Tyler Manzo		TIME COMPLETED:	03:07 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Staff mismanaged resident medication
-Staff did not respond in a timely manner to resident's call for assistance
-The facility call system is in disrepair

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 01/14/2026 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced complaint inspection visit to deliver findings regarding the complaint allegations received. LPA met with administrator, Tyler Manzo, LPA explained the purpose of the visit.

Regarding the allegation that staff mismanaged resident medication, the Department conducted an investigation that included a review of records, documentation, and interviews. The investigation determined that Resident R1 did not receive the prescribed morning dose of medication due to a depleted medication supply. The facility provided documentation indicating that measures were taken to address the depletion of the medication supply. The facility reported no incident in which Resident R1 was affected as a result of the depleted medication supply.

continue to 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 26-AS-20251027221630

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/14/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation that staff did not respond in a timely manner to the resident’s call for assistance, the Department conducted an investigation that included a review of records and interview. The LPA observed the Administrator and Director of Resident Services test the call buttons, bed sensor, and pull cords in different resident rooms in each floor of the facility. Caregiver staff responded to each activation within an appropriate time frame. The information obtained during the investigation was contradictory, and there was insufficient documentation and corroborating evidence to substantiate that staff failed to respond to the resident’s request for assistance in a timely manner during the investigation period.

Regarding the allegation that the facility’s call system was in disrepair, the Department conducted an investigation that included a review of records and an interview with the resident R1. The LPA observed the Administrator and Director of Resident Services test the call buttons, bed sensor, and pull cords, confirming that activation generated timely alerts to staff. The information obtained during the investigation was contradictory, and there was insufficient documentation and corroborating evidence to substantiate that the call system was malfunctioning.

Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove whether the allegations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed and a copy of this report is provided to the administrator.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 2