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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202351
Report Date: 01/03/2024
Date Signed: 01/05/2024 07:52:27 AM


Document Has Been Signed on 01/05/2024 07:52 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:LOLA BULLOCKFACILITY TYPE:
740
ADDRESS:1039 E EL CAMINO REALTELEPHONE:
(408) 720-8498
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:150CENSUS: 123DATE:
01/03/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Lola BullockTIME COMPLETED:
04:16 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Legal/Non-compliance inspection and met with Executive Director (ED) Lola Bullock.

The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) office after a Non-Compliance Conference held on 07/25/2023. The case management of inspections will be conducted every 3 months for 2 years.

LPA reviewed the plans and policies regarding the resolution for the prior deficiencies with ED. LPA obtained a copy of the plans and policies addressing the resolutions for the prior deficiencies. LPA obtained the staff training records. LPA discussed with ED regarding the facility protocol of completing residents' appraisals/reappraisals and training provided to staff regarding appraisal/reappraisals for residents, identifying fall risk residents and maintaining a list of fall risk residents and the safety plans for them.

LPA discussed with ED regarding residents' needs and service plans, residents' hospital discharge orders, doctor orders and the changes of resident care plans are enforced and met. LPA discussed with ED regarding the residents' medications administration and maintenance of resident medication records. LPA discussed with ED regarding the duties and responsibilities of Administrator and staff to ensure residents' needs are met. LPA discussed with ED regrading providing regular staff training with medications, appraisal/reappraisal, care and supervision, and fall risk and prevention of fall.

LPA toured the facility with ED including the memory care unit, assisted living unit, wellness center, dining room, kitchen, activity room and laundry room.

Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
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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