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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201442
Report Date: 07/17/2026
Date Signed: 07/17/2026 12:38:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2026 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20260413133217
FACILITY NAME:BELMONT VILLAGE SAN RAMONFACILITY NUMBER:
079201442
ADMINISTRATOR:COONS, JENNIFERFACILITY TYPE:
740
ADDRESS:1000 WALNUT DRIVETELEPHONE:
(925) 242-1000
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:176CENSUS: 173DATE:
07/17/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director, Jennifer CoonsTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee did not ensure staff were adequately trained to provide care to residents
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20260413133217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BELMONT VILLAGE SAN RAMON
FACILITY NUMBER: 079201442
VISIT DATE: 07/17/2026
NARRATIVE
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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.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2026 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20260413133217

FACILITY NAME:BELMONT VILLAGE SAN RAMONFACILITY NUMBER:
079201442
ADMINISTRATOR:COONS, JENNIFERFACILITY TYPE:
740
ADDRESS:1000 WALNUT DRIVETELEPHONE:
(925) 242-1000
CITY:SAN RAMONSTATE:CAZIP CODE:
94583
CAPACITY:176CENSUS: 173DATE:
07/17/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director, Jennifer CoonsTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not ensure resident's toileting needs were met
INVESTIGATION FINDINGS:
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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
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20260413133217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BELMONT VILLAGE SAN RAMON
FACILITY NUMBER: 079201442
VISIT DATE: 07/17/2026
NARRATIVE
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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.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20260413133217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELMONT VILLAGE SAN RAMON
FACILITY NUMBER: 079201442
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2026
Section Cited
CCR
87623(b)(2)(A)
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(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:
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By POC facility agrees to have staff trained as required by regulation and submit trainings to CCLD.
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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.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5