198601646-5-6-2026-11-AS-SCIS-DU8VQX-20260519163905

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 05/06/2026
Date Signed: 05/06/2026 03:22:58 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
04/27/2026 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20260427094855

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: 124	DATE:	05/06/2026
		UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Tiffany Alisafe, Memory Program Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident was illegally serviced an eviction

INVESTIGATION FINDINGS:

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On 5/6/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Memory Program Coordinator, Tiffany Alisaje and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 5/6/26 LPA Felisa Shirley reviewed copies of the following records: Staff and Resident Roster, Residence and Services Agreement, Breach of the Resident Services Agreement and the Resident Handbook Notice, 30-Day Notice to Terminate, Identification and Emergency Information, and Physician’s Report. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff - 1 – Staff - 7(S1 – S7), and Resident -1 (R1).

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260427094855

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: 05/06/2026

NARRATIVE

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The investigation revealed the following:

Allegation: Resident was illegally serviced an eviction

It is being reported that R1 was served an eviction notice derived from scenarios that did not occur.

Per review on 5/6/26, of the Residence and Services Agreement, R1 has resided at this facility since 12/28/23. On 5/6/26, LPA Shirley observed that R1 acknowledged and signed the Resident Handbook on 12/28/23. On 5/6/26, LPA Shirley observed the, Breach of the Resident services Agreement and the Resident Handbook signed by the Senior Vice President of Regulatory Affairs, dated 11/5/25 stating that R1 has engaged in multiple improper and inappropriate actions in the treatment of staff members at Belmont Village Senior Living. On 5/6/26, LPA Shirley also reviewed the 30 – Day Notice to Terminate, dated 4/21/26 with an effective day on or before 5/21/26. Eviction notice dated 4/21/26 was in compliance and within Title 22 Regulations and was accepted on 4/29/26.

LPA interviewed staff 1 – staff 7 (S1 – S7). Of those interviewed 7 out of 7 denied the allegation. LPA interviewed resident 1 (R1), who confirmed the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Resident was illegally serviced an eviction,“ therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Memory Care Coordinator, Tiffany Alisaje.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

LIC9099 (FAS) - (06/04)

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