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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202351
Report Date: 07/25/2023
Date Signed: 07/26/2023 01:13:52 PM


Document Has Been Signed on 07/26/2023 01:13 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
CCLD Regional Office, 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: 119DATE:
07/25/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:LOLA BULLOCKTIME COMPLETED:
02:45 PM
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A Noncompliance Conference meeting was conducted on 07/25/2023 at CCLD San Jose office. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Romeo Manzano, Licensing Program Analyst Steve Chang, Facility Administrator Lola Bullock, Senior VP of Regulatory Affairs and Quality Douglas Armstrong, Regional V. P. of Resident Care Service Sharlene Gephart, and V. P. of Operation Ann Wood.

The purpose of the Noncompliance Conference meeting was to discuss the serious violations that occurred at the facility on 03/18/2022 and 3/19/2022, which resulted in a resident sustained a fracture and missed medications in March 2022 and April 2022. Substantiated complaint findings were delivered on 12/20/2022.

Deficiencies cited on 12/20/2022 for violations of Title 22 California Code of Regulations are amended, LIC9099-D.

·87705(c)(5)(A) Care of Persons with Dementia amended to 87463(a) Reappraisal and 87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities

Facility representatives were informed during Noncompliance Conference meeting that additional civil penalties in the amount of $10,000 may be assessed pending review.

Noncompliance Conference Summary LIC 9111, and compliance plans were established during the meeting. The facility will begin a 2-year monitoring plan by licensing which includes more frequent licensing inspections. Facility will be referred to the Department’s Technical Support Program.

Report was reviewed with representatives. A copy of this report, LIC 9111 and amended LIC9099-D, were provided to Licensee.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023
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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