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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202856
Report Date: 03/22/2022
Date Signed: 03/22/2022 11:46:56 AM


Document Has Been Signed on 03/22/2022 11:46 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 LOS GATOSFACILITY NUMBER:
435202856
ADMINISTRATOR:MARTINEZ, RADHIKAFACILITY TYPE:
740
ADDRESS:5121 UNION AVENUETELEPHONE:
(408) 569-3333
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:175CENSUS: 0DATE:
03/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Radhika MartinezTIME COMPLETED:
12:00 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an announced pre-licensing inspection. LPA met with representatives - Senior Executive Director Radhika Martinez (ED) and Senior Vice President of Regulatory Affairs & Quality Douglas Armstrong (VP). This facility has 4 stories, and a capacity of 175 residents. Fire clearance approved for 175 non-ambulatory residents of which 100 may be bedridden. First floor contained the memory care wing of the facility. Second, third and fourth floors were for assisted living residents. No residents were observed to have moved in to the premises currently.

LPA toured the facility inside and outside with ED and VP. A sign-in sheet and COVID-19 questionnaire were present at the reception area. The facility was well lit and in good repair, LPA did not see any damaged window screens, cracked floors, broken furniture, etc. Facility's common areas, such as dining rooms, screening room, activities rooms, gymnasiums, etc were furnished and had functioning light fixtures. LPA toured the restrooms in all floors, and 10 resident rooms. All restrooms had grab bars installed. Residents' bathrooms had nonskid floors. Hot water temperature was measured to be between the of ranges of 115.7 to 120.0 degrees F.

The elevator was functioning in the facility. Facility refrigerators were observed to be fully operational in the kitchen. Kitchen observed to contain over 2 days of nonperishable and 7 days of perishable foods. The centrally stored medication rooms in each floor were locked, ready for storage and observed to have a 30 day supply of PPE. LPA observed the carbon monoxide/smoke detectors and alarms. LPA randomly inspected the fire extinguishers in each floor. They were fully charged, last serviced in 02/03/2022. There was no open body of water outside the facility. All passageways and emergency exits observed to be clear of obstruction.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
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 2


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 LOS GATOS
FACILITY NUMBER: 435202856
VISIT DATE: 03/22/2022
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Component III orientation was waived for this facility due to ED's prior experience. No issues noted during the pre-licensing inspection. The physical plant is approved pending the completion of Centralized Application Bureau (CAB) review of the facility application. Exit interview conducted with and copy of report provided to Radhika Martinez, Senior Executive Director.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2