Belmont Village San Ramon

Allegation investigated: Licensee did not ensure staff were adequately trained to provide care to residents

On 7/17/2026 at 11:30 AM, Licensing Program Analyst (LPA), A. Gomez arrived unannounced to deliver complaint findings for the allegations above. LPA met with Executive Director, Jennifer Coons and explained the reason for the visit. During the course of the investigation interviews were conducted, resident records were collected, and available trainings were reviewed. report continues on LIC9099-C Substantiated On the allegation Licensee did not ensure staff were adequately trained to provide care to residents LPA requested documentation for staff who were trained by an approved medical professional to assist R1 and R2 with their catheter. Facility was unable to provide the document and stated that a medical professional did not train specific staff to assist R1 or R2 with their catheter as required by regulations therefore the allegation is Substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided. On the allegation Staff did not ensure resident's toileting needs were met LPA conducted interviews, reviewed records, and available reports. on 4/20/2026 LPA requested records for all residents utilizing a catheter and identified R1 and R2. LPA observed through record review that R1 was on hospice. While at the facility R1's catheter was managed by Kaiser Hospice. Kaiser hospice changed the catheter and facility staff would only assist in draining the bag. Area director of Clinical Services states that R1 was receiving checks every 2-4 hours by staff however there was not a log to validate. LPA spoke with Area director of Clinical Services who states that S1 had brought a concern of R1's incontinence not being managed properly and them being excessively wet. LPA reviewed records and found that S1's concern resulted in an internal investigation. It was found that R1 had an "eroded urethra due to long term use of an indwelling foley catheter" "Additionally R1 had an open wound on the left thigh that began draining large amounts". LPA reviewed hospice care notes that support the findings. On the date related to the concern it was found that R1 had requested medications from S2 at approximately 5am. At approximately 5:35am S2 was notified by staff that R1 was wet and went to change R1 and their linens. At approximately 6:36am R1 was identified as wet again. S2 observed that this excessive wetness was a new condition and the facility attempted to contact Kaiser Hospice to notify them of the change in condition and then was able to make contact at approximately 8:40am. Hospice came later the same day to assess the catheter and discussed possible alternatives with the resident however due to them being on hospice they did not want to make an adjustment to the catheter. LPA reviewed R2's records and there was no records of wetness and their catheter has had no issues. R2s records show that their catheter is managed by home health and that staff only help to drain the bag. Therefore the allegation is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of report provided.the state’s words, verbatim · CDSS document, Jul 17, 2026 · control 15-AS-20260413133217

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87623(b)(2)(A) · Plan of correction due date: Jul 24, 2026

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance. (A) The bag may be emptied by facility staff who receive instruction from an appropriately skilled professional. This requirement is not met as evidence by: Based on record review and interview that Facility did not comply with the section cited above by staff not have been trained by a appropriately skilled professional to assist R1 and R2 with their catheter care which poses a potential health and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: By POC facility agrees to have staff trained as required by regulation and submit trainings to CCLD.

Allegation investigated: Facility mismanaging residents medications Facility not keeping accurate medication records/log

On 03/4/2026 at 12:00 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct the initial 10-day visit and deliver findings for the above allegations. LPA explained the purpose of the visit with Executive Director (ED) Jennifer Coons. LPA conducted interviews with staff, inspected med carts , reviewed records, and toured memory care. Report continues on LIC9099-C Substantiated On the allegation "Facility mismanaging residents medications" and "Facility not keeping accurate medication records/log" LPA observed that the medications for R1, and R2 are being mismanaged. LPA observed medication counts for R1 were off. LPA observed a prescription for R1 that stated for them to take 1 tablet daily had a half tab and staff where unable to explain why. ED states that R1 used to manage their own medication however when the facility took over the proper procedure may not have been done to ensure that the counts were correct. LPA also observed several duplicate medications for R1 that were being used simultaneously when the excess should have been stored in over-flow. LPA also observed that at approximately 1:00pm that R2 had not been administered any of their morning medications. LPA also observed that the proper documentation was not done in the E-MAR as to why the medications were not administered. Through interviews with staff LPA found that they were not familiar with how to properly document medication refusals/ late administration or familiar with medication administration procedures. ED states that they had already identified that staff needed additional training and that it is scheduled for March 9-11 2026. Therefore the allegations "Facility mismanaging residents medications" and "Facility not keeping accurate medication records/log" are Substantiated. ***Civil Penalties assessed for $250 for repeat violation in 12 month period*** Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 4, 2026 · control 15-AS-20260227115032

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 18, 2026

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...for the provision of adequate services. This requirement was not met as evidence by: Based on interview and record review staff did not know how to provide proper medication assistance which attributed to medication mismanagment for R1 and R2 which poses a potential health and personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: By POC facility agrees to have all med-techs retrained and recertified and notify CCLD. Civil Penalty Assesed

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(3) · Plan of correction due date: Mar 18, 2026

(c) If the resident's physician has stated... all of the following requirements are met:(3 )A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. Based on interview and record review staff did not properly document the PRN history for R2 which poses a potential health and personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: By POC facility agrees to have all med-techs retrained and recertified and notify CCLD.

Type of visit: Case Management - Other

On 3/4/2026 at 4:40pm, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a Case Management visit. LPA met with Executive Director (ED) Jennifer Coons and explained the purpose of the visit. While LPA A. Gomez was conducting a complaint investigation (15-AS-20260227115032) on 3/4/2026. LPA observed unlocked/unsecured scissors in 3 memory care resident rooms. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 4, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidence by Based on observation the facility failed to identify dangerous items in residents room. LPA observed scissors in 3 seperate memory care residents rooms which poses an imediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: Scissors were removed POC clear.

Type of visit: Case Management - Incident

On 2/6/2026 at 10:00AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit in regards incident report received 2/5/2026. LPA met with Executive Director (ED), Jennifer Coons and explained the reason for the visit. It was reported that on On 1/31/26, at approximately 9am, resident one (R1) was provided medication of another resident two (R2), in error by staff one (S1). ED states that S1 has since resigned from their position. ED also states that S1 previously had made medication errors/process errors and they received additional training. R1 did not sustain any negative side effects as a result of this error. ED states that S1's responsible parties where notified of the incident. ED states that R2 was not notified but that they took responsibility in notifying the pharmacy of the missing meds and replacing them. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 6, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 6, 2026

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...for the provision of adequate services. This requirement was not met as evidence by: Based on record review of S1s personnel file the facility did not meet the above requirement by S1 having a prior issue related to administering residents medications which resulted in R1 receiving R2's medication on 1/31/2026 which posed a potential health and personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Feb 6, 2026

Plan of correction: S1 has resigned and facility provided additional guidance POC clear

Type of visit: Required - 1 Year

On 1/22/2026 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director (ED), Jennifer Coons and explained the purpose of the visit. The facility’s fire clearance was approved for 176 non-ambulatory of which 100 may be bedridden. LPA toured the facility with ED including but not limited to 7 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. Pool observed locked with an appropriate gate. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ bathrooms were measured at 109, 116.8, 116.6,107.5, and 116.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid flooring. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Freezer temperature measured at -1 degrees Fahrenheit and refrigerator at 39 degrees Fahrenheit. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LPA reviewed 6 residents records. LPA reviewed 5 staff records and 5 of 5 are associated to the facility. LPA reviewed a sample of resident’s medications. LPA observed that at least 1 person on each shift has a valid CPR certificate. Report continues on LIC809-C Fire extinguishers were last serviced on 1/8/2026. Emergency Disaster Plan was last posted on 6/18/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 12/10/2025. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 22, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 9/23/2025 at 3:00PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit in regards to three incident reports received between 8/23/2025- 9/9/2025. LPA met with Executive Director, Jennifer Coons and explained the reason for the visit. It was reported that on 8/23/2025 R1 had a fall that resulted in a right hip fracture. On 8/24/2025 R2 had a fall that resulted in a right hip fracture. On 9/9/2025 R3 had a fall that resulted in a right hip fracture. R1 and R3 are both memory care residents. LPA reviewed the footage of R1's fall and saw that it was not at fault of anyone and that staff responded to the fall within seven minutes. R1 was transferred to the hospital by paramedics and responsible parties notified. LPA interviewed Director of Resident Care Services (DRCS) in regards to R2 and R3 falls and found that staff located R2 when staff came to assist them with their morning ADL's. R2 did not activate their pendent however. R2 was also sent out to the hospital and responsible parties notified. DRCS states that on the night of the fall when R3 came out of their apartment to see what the noise was they fell. Staff located R3 quickly after the fall because they were next door assisting another resident when it happened which is what initially woke R3 up. R3 was transferred to the hospital by paramedics and responsible parties notified. R1 has since returned to the facility with an updated care plan. R2 and R3 have not yet returned but will be reassessed before returning. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 23, 2025

Type of visit: Prelicensing

On 1/09/2025 at 1:45PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a second announced pre-licensing visit. LPA met with Executive Director, Jennifer Coons. The facility currently has no residents. LPA inspected the issues that were noted during the first pre-licensing visit. All issues are corrected and observed. Random hot water temperatures were measured and were between 111.7 and 113.8 degrees Fahrenheit No Issues were noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required. Exit interview conducted with Administrator and a copy of this report provided. COMP III waivedthe state’s words, verbatim · CDSS document, Jan 9, 2025

Type of visit: Prelicensing

On 1/07/2025 at 8:55 AM, Licensing Program Analyst (LPA) A. Gomez arrived announced to conduct a Pre licensing inspection. LPA met with Executive Director, Jennifer Coons and explained the purpose of the visit. The facility currently has no residents. LPA toured facility with Executive Director including but not limited to 18 bedrooms, 18 bathrooms, kitchen, common areas and courtyards. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Extra linens and hygiene supplies were available. There is sufficient lighting throughout facility. Room temperature was maintained at 72 degrees F and a sample of hot water temperature was measured over at 120 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational and facility has an interconnected sprinkler system. Fire extinguisher was last serviced on 5/13/2024. Facility pool is secured with fence and key fob activated lock from the outside. Kitchen freezer temperature was maintained at -4 degrees F and refrigerator at 38 degrees F. LPA observed the following: Hot water temperature is measuring over 120 degrees F ***Facility is not ready to be licensed*** LPA will inform CAB analyst upon receipt of proof of corrections. Final review of application, and license to be granted by CAB analyst. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 7, 2025

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: Initial Capacity: 176 Census (if any clients in care): 0 COMP II Participants: Jennifer Coons (administrator); Douglas Armstrong (applicant/licensee) Interview Method: microsoft teams On 11/27/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Nov 27, 2024