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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202351
Report Date: 04/02/2021
Date Signed: 04/26/2021 10:00:46 AM


Document Has Been Signed on 04/26/2021 10:00 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:BELMONT VILLAGE SUNNYVALEFACILITY NUMBER:
435202351
ADMINISTRATOR:SINGH, RADHIKAFACILITY TYPE:
740
ADDRESS:1039 E EL CAMINO REALTELEPHONE:
(408) 720-8498
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:150CENSUS: 115DATE:
04/02/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Lola BullockTIME COMPLETED:
12:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced tele-Case Management - COVID-19. LPA virtually met with the Executive Director (ED) Lola Bullock.

On 10/06/2020, The Department issued a Provider Information Notices (PINS) PIN 20-38-ASC UPDATED GUIDANCE ON CORONAVIRUS DISEASE 2019 (COVID-19) AND STATEWIDE WAIVER RELATED TO VISITATION. The PIN stated facilities without COVID-19 case "should conduct surveillance testing of 25 percent of all staff every 7 days (e.g., choose different staff to test every 7 days). The purpose of a surveillance testing strategy is to monitor the spread of the virus in order to isolate the virus and mitigate outbreaks."

On 03/24/2021, it came to the Department's attention that the facility was testing staff only who did not receive COVID-19 vaccination.

On 03/26/2021 and 03/29/2021, LPA contacted different staff from the facility and confirmed the allegation. Thus, it was confirmed that the facility was not following the guidance from the Department.

A deficiency was cited today as per California Code, Health and Safety Code. See 809-D for more information. Failure to correct the deficiencies may result in civil penalties.

This report was reviewed with ED, and a copy was emailed to obtain a signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2021
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 04/26/2021 10:00 AM - 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
CCLD Regional Office, 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: 04/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/05/2021
Section Cited

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1568.082(3) Conduct which is inimical to the health, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.
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Licensee/administrator failed to comply and cooperate with technical assistance recommendations provided by local public health and CCL on 25% surveillance testing of staff regardless of vaccination status weekly. This poses an immediate risk to the health of the residents 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: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2021
LIC809 (FAS) - (06/04)
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