Belmont Village San Jose

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff hit resident

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Rachel Brown. On September 3, 2025 the Department received a complaint alleging Staff hit resident. It has been alleged staff S1 hit resident R1. On September 9, 2025, LPA Monter conducted the initial complaint investigation visit. LPA attempted to interview resident R1. R1 stated he/she declined to be interviewed. Page 1 Out of 4. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 4, 2025 · control 26-AS-20250903112859

Allegation investigated: Facility staff had inappropriate behavior with a resident

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegation. LPA met with Executive Director, Rachel Brown. On 03/11/2025, the Department received the complaint. On 03/12/2025, the initial complaint investigation was conducted. Documents were obtained to include 5 residents physician's report, service plan, progress notes from February - March 2025, resident roster, staff schedule, and police report. It was alleged that a staff had inappropriate behavior with a resident (R1). Another resident (R2) was the first person to have reported the information to the staff. R2 reported that a staff was having inappropriate behavior with R1. R2 could not provide a name of the staff who had inappropriate behavior with R1 but provided a description of the staff. R2 states that the inappropriate behavior was consensual per R1. Page 1 of 2. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 22, 2025 · control 26-AS-20250311090818

Allegation investigated: Staff inappropriately restrained a resident while in care

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegation. LPA met with Executive Director, Rachel Brown. On 03/24/2025, the Department received the complaint. On 04/03/2025, the initial complaint investigation was conducted. The following documents were obtained to include a resident’s physician’s report, service plan, progress notes, resident roster and police report. It was alleged that on 10/27/2024 a staff member (S1) held the wrist down of a resident (R1) for about 15 seconds in order to “check his/her strength”. It was reported that R1 attempted to get his/her wrist away from S1 but was unable to do so. The incident was observed by a staff (S2) who stopped the incident. R1 did not sustain any injuries and did not recall the event due to his/her diagnosis of a neurological condition. Page 1 of 3. Substantiatedthe state’s words, verbatim · CDSS document, Jul 22, 2025 · control 26-AS-20250324143221

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: - Facility is not kept clean - Dishes to serve residents food are dirty

On 02/05/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver the findings regarding the received allegations. LPA met with executive director Rachel Brown and explained the purpose of today's visit. During the course of the investigation interviews were conducted, observations were made, and documents were received. Based on the information provided there are dishwashers present at the facility and substantial food supply observed. Per interviews any dishes that do not meet standards are usually replaced with new or cleaner dishes. Some cutlery and mugs were observed to have staining but this was not apparent on all mugs, cups, dishes, and cutlery. These allegations are unsubstantiated based on the totality of observations made and investigation conducted. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of ethe state’s words, verbatim · CDSS document, Feb 5, 2025 · control 26-AS-20230313164543

Allegation investigated: - Facility does not respond to emergency pull cord signals in a timely manner. - Facility not providing medications to resident when requested - Facility is not providing contracted services - Facility is not changing resident's urine bag

On 02/05/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver the findings regarding the recieved allegations. LPA met with executive director Rachel Brown and explained the purpose of today's visit. During the course of the investigation interviews were conducted, observations were made, and documents were received. Call logs show a pattern of responsiveness that were best met by time and staff on hand to be resonable depending on the service needed. Medication records observed and interviews show that all prescribed medications were given as prescribed and directed, this would include the changing of the resident's urine bag. When alerted staff would respond based on the demand of staffing and business of the facility. Staff are not informed of the type of service needed when called upon but do respond based on the records reviewed. The resident did not have one on one caregiving. All services were met by the facithe state’s words, verbatim · CDSS document, Feb 5, 2025 · control 26-AS-20240304153845

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident's hygiene needs not being met. Medications not given to resident according to physician's instructions. Lack of supervision resulting in resident wandering from the facility. Facility is charging for services not provided.

Licensing Program Analyst (LPA) Steve Chang conducted a complaint investigation visit to deliver investigation findings and met with Memory Program Coordinator (MPC) Allyson Fuji. On 08/16/2021, the Department received a complaint of the above allegations. On 8/20/2021, an initial complaint investigation visit was conducted. LPA interviewed ED and two staff (S1, S2). Residents Physician reports, medical records, Appraisal Needs and Services Plan of Residents, Admission Agreement, And the facility Activity Programs documents were obtained. . Continued on LIC9099-C. page 1 of 4 Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 28, 2023 · control 26-AS-20210816084035

Allegation investigated: Resident sustained an injury from a fall while in care Staff did ensure a resident consumed an appropriate amount of fluids while in care Staff did not follow resident's medical orders

/29/2020 On 09/25/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Director of Resident Care Services, Gilda Deocares and explained the purpose of today's visit. Regarding the allegation, resident sustained an injury from a fall while in care, it was reported that resident (R1) was sent to hospital after a fall and injuring the head. According to Reporting Party (RP), he/she was made aware by a caregiver that R1 was sent to the hospital. RP noticed that R1 had a bump in the head but days later the face was bruised, but since has faded. Based on record reviews, an incident report on 12/18/2020 was sent to CCLD that R1 was sent to hospital due to an unwitnessed fall. LVN was alerted through an electronic monitoring system in the facility. 911 was called and upon further assessment by paramedics, R1 was brought to hospital for further evaluation. In this report it was also stated that R1 tried to getthe state’s words, verbatim · CDSS document, Sep 25, 2023 · control 26-AS-20201217135141

Allegation investigated: Staff did not protect resident from physical abuse.

On 09/25/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Director of Resident Care Services, Gilda Deocares and explained the purpose of today's visit. Regarding the allegation, staff did not protect resident from physical abuse. It was reported that the resident (R1) sustained bruising that looked like fingers while being under the care of a private caregiver (P1). P1 also locks R1s room which is not allowed. Based on record reviews, an earlier report was sent to CCLD on 12/14/2020 regarding the bruising on R1s forearms found by another private caregiver (P2). R1 is taking medication that makes skin more conducive to bruising. After the report was also received by the responsible party (RP), RP requested the agency to provide a different private caregiver who can be more suited for the R1s care needs. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 25, 2023 · control 26-AS-20201229100834

Allegation investigated: Facility not being cleaned adequately. Facility did not communicate with authorized representative about leaving facility. Residents not wearing mask on outing.

On 09/25/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Director of Resident Care Services, Gilda Deocares and explained the purpose of today's visit. Regarding the allegation that facility is not being cleaned adequately, Reporting Party (RP) mentioned that the resident's (R1) room was dusty, dirty toilet and mold in sink. Based on interviews, housekeeping are done once a week in residents room. There are occassions where residents or family member request the room to be cleaned due to accidents or incidents and facility addresses these requests promptly. Aside from weekly housekeeping, constant checks are done in rooms and trash is being emptied accordingly. LPA toured the room and it didn's show any molds. Bathroom is clean and all of the residents belongings are intact. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 25, 2023 · control 26-AS-20210812151804

Allegation investigated: Resident not being provided adequate food service. Facility is in disrepair.

On 09/19/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Memory Program Coordinator, Allyson Fujii and explained the purpose of today's visit. Regarding the allegation of resident not being provided adequate food service, it was reported that resident (R1) was only provided grilled cheese. Based on interviews and record reviews, R1 likes to eat sandwiches and salads. A caregiver (S1) stated that R1 loves eating salads. As for sandwiches, R1 likes grilled cheese or peanut butter and jelly. While R1 may have specific preference on what to eat, suggestions and options are also given to them. Facility menus have extensive choices for residents. R1 also has an option on what she/he wants to eat. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 19, 2023 · control 26-AS-20210812151804

Allegation investigated: Staff caused injury to resident.

Amended report On 12/5/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Executive Director Rachel Brown & emory Program Coordinator, Allyson Fujii and explained the purpose of today's visit. Regarding the allegation of staff causing injury to resident, Licensing received a report regarding a resident (R1) being injured due to a caregiver grabbing R1s arm and causing a bruise. R1 is a resident that was diagnosed with mixed dementia and has inappropriate and aggressive behaviors. Assistance on transfers and showering is also assessed for R1. R1 is also 99 years old when the allegation was filed. Based on interviews four out of four staff members mentioned that R1 is always combative and aggressive. When R1 calls for help and as staff approaches to assist, R1 will start kicking. Staff always waits for R1 to calm down due to R1 being agitated or confused before helping again. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 19, 2023 · control 26-AS-20210201161703