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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 10/09/2025
Date Signed: 10/09/2025 03:36:09 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
08/26/2025 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20250826170519
FACILITY NAME:BELMONT VILLAGE RANCHO PALOS VERDESFACILITY NUMBER:
198601646
ADMINISTRATOR:BALBIN, RALPHFACILITY TYPE:
740
ADDRESS:5701 CRESTRIDGE RDTELEPHONE:
(310) 377-9977
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:150CENSUS: 134DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:ADMINISTRATOR RALPH BALBINTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident sustained a fracture while in care.
INVESTIGATION FINDINGS:
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On 10/09/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Belmont Village Rancho Palos Verdes and was greeted by Administrator Ralph Balbin (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following: LPA Calderon interviewed Staff S1-S5, resident R1-R12, witness (W1). LPA Calderon obtained the following records: Admission Agreement (dated 06/04/2014). Email from resident family members (dated 10/01/2025), Incident report (dated 08/25/2025), Preplacement Appraisal (dated 05/05/2014), Physician order (dated 10/05/2025), Resident Assessment Plan (dated 07/01/2025), Physician Report (dated 07/22/2024) for R1.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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 2
Control Number 11-AS-20250826170519
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: 10/09/2025
NARRATIVE
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Regarding the Allegation: Resident sustained a fracture while in care.

This complaint alleged that the facility staff dropped R1 and caused fractures to leg. LPA Calderon noted staff giving morning medications to residents. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions. Reviewed incident report (dated 08/25/2025), report indicates that R1 complained of pain. The report does not suggest that R1 was dropped by staff or had a fall. The preplacement appraisal (dated 05/05/2014) noted R1 has osteoporosis and vitamin D deficiency. Physician Orders (dated 10/05/2025) noted vitamin D3. Reviewed the discharge paperwork for R1. Torrance Memorial Hospital records indicate that R1 has cognitive issues and no mention of osteoporosis. The Physician Report (dated 07/22/2024) indicates that R1 has osteoporosis. The residential care plan (dated 07/15/2025) indicates osteoporosis with vitamin D needed. 5 out of 5 staff deny the allegation. R1 cannot be interviewed due to cognitive issues. 11 out of 12 residents deny the allegation.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “resident sustained fracture while in care” is found to be UNSUBSTANTIATED.

No deficiencies cited during today's visit.



An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Ralph Balbin (S1).
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
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