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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202856
Report Date: 03/13/2026
Date Signed: 03/13/2026 12:46:16 PM

Document Has Been Signed on 03/13/2026 12:46 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BELMONT VILLAGE LOS GATOSFACILITY NUMBER:
435202856
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, RADHIKAFACILITY TYPE:
740
ADDRESS:5121 UNION AVENUETELEPHONE:
(408) 559-3333
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 175CENSUS: 135DATE:
03/13/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Radhika MartinezTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (ADM) Radhika Martinez.

The purpose of the visit was to follow up on two incidents reported by the facility via Unusual Incident/Injury Report (IR). The first IR was submitted on 02/20/2026 and stated that on 02/20/2026, resident R1 exited the facility via a stairwell exit door. R1 was wearing a bracelet that allowed staff to locate him/her. The bracelet indicated that R1 was about a block away from the facility. Facility staff located R1 and escorted R1 back to the facility.

During visit on 03/13/2026, LPA Marrufo interviewed Administrator (ADM) Radhika Martinez. ADM stated that R1 lives in the Assisted Living portion of the facility. ADM stated that during the incident, staff were alerted that an exit door had been used and immediately conducted a head count of the residents. ADM stated staff realized after the head count that R1 was missing from the facility and continued to search for R1 within the facility instead of alerting management. ADM stated management staff later used a mobile application that identified the location of R1’s bracelet. R1 was found about a block away from the facility. ADM stated that staff have been trained in-service to immediately utilize the mobile application that identifies the residents’ locations using their bracelets.


See LIC809-C page for more information. Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2026
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BELMONT VILLAGE LOS GATOS
FACILITY NUMBER: 435202856
VISIT DATE: 03/13/2026
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During visit on 03/13/2026, LPA Marrufo obtained a copy of R1’s Physician’s Report. The Cognitive Conditions section of R1’s Physician’s Report states it is “unknown at this time” if R1 has Mild Cognitive Impairment and “unknown at this time” if R1 has Dementia/Major Neurocognitive Disorder. The Physician’s Report states that if R1 had dementia, R1 does not require supervision when leaving the property due to dementia or cognitive decline. R1’s Physician’s Report states R1 does not have disorientation, unsafe wandering, elopement, or sundowning behavior.

The second IR was submitted on 12/12/2025 about an incident that occurred on 12/09/2025 involving staff S1 giving R2 medications M1-M6, which belong to R3. S1 stated R2 and R3 have a similar physical appearance and S1 mistook R2 for R3. Facility staff informed R2’s physician and family and sent R2 to the hospital as a precaution.

During visit, ADM stated that every resident’s Medication Administration Record (MAR) has a photograph of the resident. ADM stated to have trained staff to verify the identity of the resident by using the photograph in the resident’s MAR and by asking the resident for his or her name prior to assisting a resident with administering medications. ADM stated that S1 checked R2’s photograph and asked R2 to verify his/her name, but R2 did not respond. ADM stated staff have been trained to ask another staff to verify the resident’s identity if the resident does not respond to a staff member’s request to verify his/her name.

On 03/13/2026, LPA Marrufo obtained a copy of R2’s Physician’s Report, which states R2 is not able to administer his/her own prescription medications.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information.

An Advisory Note was issued. See LIC9102 for more information.

This report was reviewed with Administrator Radhika Martinez and a copy of this report and appeal rights were provided.

Page 2 of 2. END REPORT
NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/13/2026 12:46 PM - It Cannot Be Edited


Created By: David Marrufo On 03/13/2026 at 12:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE LOS GATOS
FACILITY NUMBER: 435202856

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2026
Section Cited
CCR
87411(a)

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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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Licensee agrees to submit a plan of correction by 03/14/2026 stating how the licensee will ensure that staff do not administer the wrong medication to residents, including in-service training of staff on assisting residents with the administration of medications.
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 This requirement was not met as evidenced by: Licensee did not ensure that R2 was not given medications M1-M6, which belonged to R3, which poses an immediate safety risk to residents in care.
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Once in-service training is completed, the licensee will submit copies of staff training records, including names of staff trained, training dates, training topics, and names and qualifications of trainers. **In-Service Training Conducted on 01/20/2026; Deficiency cleared during visit. **

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
David Marrufo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2026


LIC809 (FAS) - (06/04)
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