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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202856
Report Date: 04/03/2023
Date Signed: 04/03/2023 04:42:05 PM


Document Has Been Signed on 04/03/2023 04:42 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
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: 99DATE:
04/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Radhika MartinezTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Steve Chang conducted a unannounced annual inspection visit, and met with Senior Executive Director (ED) Radhika Martinez.

LPA checked 5 staff records (S1 - S5) and 5 resident records (R1 - R5). LPA interviewed 5 staff (S6 - S10) and 5 residents (R6 - R10).

LPA toured the facility inside and out with ED. LPA toured the main entrance, mail box/snack room, activity room 1 & 2 in Assist Living unit, dining room in Assist Living unit, kitchen, Gym, and courtyard. LPA toured memory care unit activity room 1 & 2, dining room, and patio. The facility has 4 floors. LPA toured the Assist Living unit and Memory care unit apartments and public restrooms. LPA toured inside of apartment rooms 146, 102 and 103.

License, personal right posters, food menu, Administrator Certificate, and Specialist diet list were observed posted. Medication rooms were observed locked. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Knives storage and cleaning product rooms were observed locked. Room temperature was at 71 degree F, and hot water temperature was at 110 degree F in facility. Fire extinguishers were serviced on 2/13/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors.

No citation was noted for today's inspection.

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: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2023
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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