435202856-11-20-2025-26-AS-DMAO-DNM2RK-20251120163739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202856
Report Date: 11/20/2025
Date Signed: 11/20/2025 04:37:48 PM

Document Has Been Signed on 11/20/2025 04:37 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 GATOS		FACILITY NUMBER:	435202856
ADMINISTRATOR/ DIRECTOR:	MARTINEZ, RADHIKA		FACILITY TYPE:	740
ADDRESS:	5121 UNION AVENUE		TELEPHONE:	(408) 559-3333
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY: 175		CENSUS: 131	DATE:	11/20/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:30 PM
MET WITH:	Radhika Martinez		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (AMD) Radhika Martinez. The purpose of the visit was to follow up on two incidents self-reported by the facility. The first incident was reported via Unusual Incident/Injury Report (IR) on 07/25/2025. The IR reported that on 07/22/2025, memory care resident R1 reported to R1's family member that R1 had been raped. The IR stated that R1's child reported to the facility that R1 has previously reported being kidnapped and that people are stealing from him/her. The IR stated R1's child believed R1's allegation of rape was a hallucination. During visit, LPA Marrufo interviewed staff S1-S4. Staff S1-S4 stated to have never observed anyone physically or sexually abuse R1. LPA Marrufo obtained a copy of a law enforcement incident card, which includes the case number that was also reported on the IR and is dated 07/23/2025. The incident card stated that a police report was not taken. LPA Marrufo conducted a wellness check on R1 and observed R1 to not have any bruises on his/her hands, face, or neck. R1 was dressed in clean clothing and was sitting in a wheelchair. The second incident was self-reported by the facility via SOC341 Suspected Adult/Elderly Abuse Form and Unusual Injury/Incident Report on 11/19/2025. The SOC341 stated that memory care resident R2 hit memory care resident R3 two times on the shoulder. See LIC809-C page for more information. Page 1 of 2.

NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

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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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: 11/20/2025

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ADM stated during interview that staff have been instructed during staff meetings to keep R2 separated from other residents when R2 is exhibiting signs of being agitated and to immediately separate R2 from other residents if R2 begins hitting them.

Staff S1-S4 stated to have been given training to keep R2 separated from other residents if he/she appears agitated and to immediately separate R2 from other residents if he/she begins hitting them.

LPA Marrufo observed R2 and R3 while they were attending a live music event at the facility. LPA observed R2 and R3 sitting at separate tables.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Radhika Martinez and a copy of this report was provided.

Page 2 of 2.

END REPORT

NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: David Marrufo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC809 (FAS) - (06/04)

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