<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202351
Report Date: 04/15/2024
Date Signed: 04/16/2024 09:25:35 AM


Document Has Been Signed on 04/16/2024 09:25 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: 121DATE:
04/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Lola BullockTIME COMPLETED:
12:59 PM
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
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Incident visit and met with Executive Director (ED) Lola Bullock.

LPA explained the purpose of the visit to ED.

On 4/12/2024, the Department received an incident report regarding a resident R1 with left eye black and swollen. The incident occurred on 4/02/2024.

LPA requested R1's physician report, appraisal/needs and service plan, wellness communication log, and discharge documents.

LPA interviewed ED. ED stated R1 was found in bed on 4/2/2024, around 8:00AM with black eye and lacerations on head. R1 stated he/she fell at night and went back to the bed by self. ED stated R1 is ambulatory. R1 was sent to hospital after assessment by the facility nurse and discharged back to the facility on 4/4/2024 around 6:00PM. ED stated the facility updated R1's care plan immediately on 4/4/2024 after R1 returned back to the facility on 4/4/2024.

ED stated the witnessed caregiver and nurse are off today. ED stated the facility added a bed alarm for R1. ED stated the facility to have staff escort R1 when R1 is walking.

LPA interviewed resident R1. R1 stated he/she fell by self at night and went back to the bed by self. R1 stated the facility sent him/her to hospital. R1 stated no one abused him/her. R1 stated no one hit him/her.

No citation noted today. 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: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1