198601646-8-22-2025-11-AS-SCIS-DN75Q4-20251106190852

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 08/22/2025
Date Signed: 08/22/2025 03:20:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2025 and conducted by Evaluator Elvira Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250606113252

FACILITY NAME:	BELMONT VILLAGE RANCHO PALOS VERDES		FACILITY NUMBER:	198601646
ADMINISTRATOR:	BALBIN, RALPH		FACILITY TYPE:	740
ADDRESS:	5701 CRESTRIDGE RD		TELEPHONE:	(310) 377-9977
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	150	CENSUS: 134	DATE:	08/22/2025
		UNANNOUNCED	TIME BEGAN:	07:50 AM
MET WITH:	Nina Khatchatrian		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not abide to the admission agreement.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 08/22/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted a subsequent unannounced complaint visit to further investigate the above-mentioned allegation and deliver findings. LPA met with Nina Khatchatrian, Director of Resident Care, and the purpose of the visit was explained. LPA was granted access to the facility. Ralph Balvin, Administrator, later joined LPA Gonzalez for the visit.

The investigation consisted of the following: On 06/11/25, LPA Gonzalez requested and reviewed the following documents: staff roster, resident roster, Face Sheet, Physician's Report, Residence and Services Agreement, Amendment to Residence and Service Agreement for Change in Residence, Rent Increase notices dated: 01/10/20, 01/27/21, 01/15/22, 01/30/23, and 01/30/24, service rate notices dated: 08/07/21, 10/28/22, 10/30/23, and letters of conservatorship for resident #1 (R1). Additionally, LPA conducted interviews with staff #1-#2 (S1-S2) and attempted to interview witness #1 (W1).

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

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 3

Control Number 11-AS-20250606113252

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 08/22/2025

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
26
27
28
29
30
31
32

On 08/22/25, LPA Gonzalez received the following documents: Rent Increase letters dated: 01/10/20, 01/27/21, 01/15/22, 01/30/23, 01/30/24, and 01/28/25, Support Fee Increase letters dated: 08/27/21, 08/28/22, 10/30/23, 10/25/24, and Residence and Service Agreement. Additionally, LPA conducted interviews with staff #3 (S3), W1, residents #2-#9 (R2-R9), and attempted to interview R1.

The investigation revealed the following:

Allegation: Staff did not abide to the admission agreement. It is being alleged that a resident and/or representative never received a 60-day notice for enhanced personal care charges. It is also being alleged that the resident and/or representative never received a 60-day notice for rent increases. On 06/11/25 LPA conducted interviews with S1-S2, and on 08/22/25, LPA conducted an interview with S3. Of those interviewed, 3 out of 3 staff denied the allegation. 3 out of 3 staff stated that residents and/or representative are notified 60 days in advance regarding rent increases. 3 out 3 staff stated that residents and/or representative are notified in advance regarding any service charge increase.

On 08/22/25, LPA conducted interviews with R2-R10. LPA attempted to interview R1 but was unable to due to R1’s diagnosis. Of those interviewed, 8 out of 9 residents could not corroborate with the allegation. 7 out of 9 residents stated that staff went over the Admission Agreement with their representative and a copy was provided prior to moving in. 1 out of 9 residents stated that staff went over the Admission Agreement and a copy was provided prior to moving in. 7 out of 9 residents stated that the facility notifies their representative in advance regarding any rent increases, and service charge increases. 1 out of 9 residents stated that the facility notifies them in advance regarding any rent increases, and service charge increases. 8 out of 9 residents stated that they are receiving the services they are being charged for. 8 out of 9 residents stated that they are satisfied with the services being provided to them.

On 08/22/25, LPA conducted an interview with W1, and they indicated that the facility provides them with rent increase letters, and support fee increase letters in a timely manner, and at least 60-days in advance.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250606113252

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 08/22/2025

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
26
27
28
29
30
31
32

On 08/22/25, LPA Gonzalez conducted a review of records. LPA reviewed the Residence and Service Agreement dated 03/01/15, and it states that the facility may change any other fee described within the agreement upon sixty (60) days prior written notice to the resident and/or representative at any time during the term of the agreement. In the event of a rate increase, the facility will include with the notice of the increase the reasons for the increase and a general description of the additional costs that the facility has incurred. LPA reviewed Rent Increase letters dated: 01/10/20, 01/27/21, 01/15/22, 01/30/23, 01/30/24, and 01/28/25 and observed that all letters were mailed to R1’s current and past representatives at least 60 days prior to when the rent increase took effect. LPA reviewed Support Fee Increase letters dated: 08/27/21, 08/28/22, 10/30/23, 10/25/24 and observed that all letters were mailed to R1’s current and past representatives at least 60 days prior to when the support fee increase took effect.

Based on record review, and interviews conducted, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is unsubstantiated.

No deficiencies were cited during this investigation.

An exit interview was conducted, and a copy of this report was provided to Ralph Balvin, Administrator.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3