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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202856
Report Date: 03/19/2025
Date Signed: 03/19/2025 05:14:52 PM

Document Has Been Signed on 03/19/2025 05:14 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: DATE:
03/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:33 PM
MET WITH:Radhika MartinezTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Incident visit and met with Senior Executive Director (ED) Radhika Martinez.

On 3/19/2025, the Department received a report that a staff (S1) had an inappropriate behavior to a resident (R1). The purpose of today's visit is to obtain more information and to investigate.

LPA interviewed ED, 6 staff (S2 - S7), 5 residents ( R1 - R5), and a family member (FM) of a resident.

ED stated staff S1 was terminated by the facility because S1 was found sleeping while on duty.

ED stated this is the first incident of S1 regarding inappropriate behavior. ED stated there is no witness for the incident. 6 Out of 6 staff stated they never saw S1 had inappropriate or aggressive behavior.

R1 stated this is the first time that S1 had this kind of behavior. 1 out of 5 residents does not remember S1. 3 Out of 5 residents stated they did not see S1 had inappropriate or aggressive behavior.

LPA requested R1's physician report, appraisal needs service plan. LPA obtained the facility staff training document regarding resident abuse and reporting requirement.

This case needs further investigation.

Exit interview was conducted with ED. The report was provided to ED for review and signature. A copy of the report was provided to ED.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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