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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601646
Report Date: 07/27/2026
Date Signed: 07/27/2026 04:29:09 PM

Document Has Been Signed on 07/27/2026 04:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VERDESFACILITY NUMBER:
198601646
ADMINISTRATOR/
DIRECTOR:		BALBIN, RALPHFACILITY TYPE:
740
ADDRESS:5701 CRESTRIDGE RDTELEPHONE:
(310) 377-9977
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 150CENSUS: 123DATE:
07/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Ralph Balbin-Administrator TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 7/27/2026, Licensing Program Analyst (LPA)Bernadette Allen conducted an unannounced visit to conduct an annual inspection visit. LPA met with Ralph Balbin-Executive Director, and he was informed of the purpose of the visit.

The facility is licensed to serve (150) elderly adults aged 60 and above, of which (120) can be non-ambulatory and (30) bedridden.

Approved for delayed egress doors and secured perimeters. The facility has an approved hospice waiver for (30). Currently the facility has (123) residents.

The facility is a three-story building located within a residential neighborhood. The structure contains a total of 141 resident bedrooms, 27 bedrooms in the neighborhood area and 114 bedrooms in Assisted Living.



Each resident bedroom is equipped with its own bathroom. The facility includes a lobby, living room, three lounge areas, a dining room, kitchen, and bistro. A designated Memory Care Unit is located on site. Additional rooms and support areas include housekeeping and janitorial storage closets, three administrative offices, two laundry rooms, an activity room, a separate activity area, a Wellness room, an engineering office, and a beauty salon. The facility also features front and rear patio areas, a gated swimming pool, and multiple outdoor storage sheds.
Stephanie Cifuentes
Bernadette Allen
DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/27/2026
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At 11:10 AM, LPA reviewed six (6) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings which appeared to be current.

LPA reviewed six (6) residents’ files for admission agreements, updated physician reports, and needs and services plan which appeared to be current.


At 2:00 PM, LPA Allen and Ralph Balbin toured the physical plant. There is a pool located on the first floor, gated and locked.



LPA inspected a total of (6) bedrooms and (6) bathrooms. The beds and bedding supplies appeared to be in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed.

LPA Allen observed that the facilities kitchen to have a 5-day supply of perishables and a 7-day supply of non-perishables food items which were stored and maintained properly.

Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 105.0°F to 120F, and the room temperature ranged from 76°F to 78°F. throughout the facility.


The last Fire/Disaster Drills were conducted on 7/23/2026.

During the visit, LPA Allen observed that the facility appeared to be clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care.

An exit interview was conducted, and a copy of the Report was provided to Ralph Balbin /Executive Director.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Bernadette Allen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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