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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202856
Report Date: 05/10/2022
Date Signed: 05/10/2022 09:58:26 AM


Document Has Been Signed on 05/10/2022 09:58 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: 21DATE:
05/10/2022
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Radhika MartinezTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager Romeo Manzano, and Nurse Kathleen Weiss conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Radhika Martinez.

Administrator Radhika Martinez reports that there are currently 0 COVID-19 positive residents and 1 COVID-19 positive staff.

During today's tele-visit, the following recommendations were made to the facility by Nurse Kathleen Weiss:

1. Consider putting trash cans with lids in bathrooms

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with with Administrator Radhika Martinez. A copy of the report will be sent to her for to be signed and returned to CCL.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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