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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604562
Report Date: 02/28/2025
Date Signed: 02/28/2025 04:54:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/05/2023 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20230905110217
FACILITY NAME:BELMONT VILLAGE LA JOLLAFACILITY NUMBER:
374604562
ADMINISTRATOR:ARP, JAMESFACILITY TYPE:
740
ADDRESS:3880 NOBEL DRIVETELEPHONE:
(858) 450-2500
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:220CENSUS: 153DATE:
02/28/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director James ArpTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Staff do not provide 1 on 1 care for resident as agreed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director James Arp.

Throughout the investigation, the Department secured pertinent records and conducted interviews with several sources, including staff and residents.

It was alleged staff did not provide one on one care for a resident as agreed. An interview with an internal source revealed the facility provided private pal (caregiver) agreements as an additional service. This service provided additional assistance with activities of daily living, wellness checks, incontinence care, escorts, housekeeping services, safety support, socialization services, and companion services.

(See LIC9099C form continuation of report.)
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
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 6
Control Number 08-AS-20230905110217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE LA JOLLA
FACILITY NUMBER: 374604562
VISIT DATE: 02/28/2025
NARRATIVE
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The number of days, hours, and frequency varied and was dependent on the resident and resident’s responsible party. Most of the interviews conducted did not reveal any concerns with the agreements not being followed.

One source revealed an instance when a caregiver providing one to one assistance was asked to assist other caregivers. The resident being provided one to one assistance was escorted to a common area where other residents were supervised by staff. A separate source recalled an instance where the assigned one to one caregiver was asked to assist with meal prepping. The staff agreed and the resident being provide one to one assistance remained in the common area, within eyesight of the caregiver.

Although the residents remained under staff supervision, the agreement of one-to-one care was not followed. This deficiency was cited in an LIC 9099D page and a plan of correction was jointly formulated with the Executive Director James Arp.

An exit interview was conducted with James Arp, to whom a copy of this report, LIC 9099D, and Licensee/Appeals Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received by James Arp.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/05/2023 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20230905110217

FACILITY NAME:BELMONT VILLAGE LA JOLLAFACILITY NUMBER:
374604562
ADMINISTRATOR:ARP, JAMESFACILITY TYPE:
740
ADDRESS:3880 NOBEL DRIVETELEPHONE:
(858) 450-2500
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:220CENSUS: 153DATE:
02/28/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director James ArpTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Neglect resulting in resident sustaining serious bodily injury
Neglect resulting in resident receiving delayed medical care
Staff did not meet resident's toileting needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced a follow up complaint investigation visit and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director James Arp.

Throughout the investigation, the Department secured records and conducted interviews with external and internal sources, including staff, residents, and family members.

It was alleged neglect resulted in Resident # 1 (R1) sustaining serious bodily injury. On August 5, 2023, the Department received a complaint with allegation of neglect by staff as R1 fell and sustained a fracture.

R1 a one hundred (100) year old male resident, with pre-placement assessment dated July 7th, 2022, revealed R1 was able to manage their own medication, and did not require assistance with grooming, dressing, toileting, nor eating. R1 was in good mental and physical health. R1 did use a walker, or scooter to ambulate, and the facility provided weekly assistance with bathing and laundry service.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
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 6
Control Number 08-AS-20230905110217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE LA JOLLA
FACILITY NUMBER: 374604562
VISIT DATE: 02/28/2025
NARRATIVE
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R1’s Physician’s Report (LIC 602) dated July 12th, 2022, revealed a primary diagnosis of Hyperlipidemia (HLD), Spinal Stenosis (cervical), and Sciatica. A secondary diagnosis of Gerd, and Neuropathy of fingers. No cognitive impairment was disclosed in this report.

A records review that included the facility and nurses’ notes dated March 13th, 2023, revealed that R1 was found on the floor by staff, who summoned Emergency Medical Services (EMS). The facility and nurses notes further revealed that on March 14th, 2023, upon R1’s request, staff transported R1 to urgent care with complaint of pain. An X-ray revealed R1 had a rib fracture and medication was prescribed. R1 declined further testing and denied any head injuries had occurred.

Interviews with staff confirmed that staff responded to R1’s call for help, evaluated R1 and EMS was summoned. Interviews with staff and R1’s relative confirmed R1 had a history of declining medical assistance and often declined to be transported to the hospital for further evaluation. During this incident, Staff and a relative encouraged R1 to obtain medical evaluation from emergency personnel, but R1 continued to decline further evaluation.

Based on evidence obtained, staff responded quickly, evaluated R1 and summoned EMS. R1 was R1’s own responsible party and declined further medical attention, therefore, the allegation was Unsubstantiated.

It was alleged neglect resulted in R1 receiving delayed medical care. During R1’s fall on March 18th, 2023, there were no visible injuries, but R1 complained of right-side pain. Staff were unable to determine if R1 struck their head during the fall. Paramedics were immediately called and assessed R1 for injuries. Paramedics advised R1 to be transported to the hospital for further evaluation, but R1 refused. R1’s relative was called while paramedics were still present and tried to convince R1 to be transported to the hospital for evaluation. R1 still refused.

R1 was their own POA and in charge of their own medical care. The evidence shows that R1 was immediately provided emergency services after the fall, but R1 declined further evaluation against the paramedic’s advice. Therefore, the allegation of Neglect/Lack of Care and Supervision resulting in untimely medical care was Unsubstantiated.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20230905110217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE LA JOLLA
FACILITY NUMBER: 374604562
VISIT DATE: 02/28/2025
NARRATIVE
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It was alleged staff did not meet resident's toileting needs. Interviews with several sources, including staff and residents, denied having concerns with lack of incontinence care, or with lack of assistance with toileting. Sources consistently reported staff would respond within a reasonable time to residents’ requests. The allegation was unsubstantiated based on the evidence obtained during the investigation.

An exit interview was conducted Executive Director James Arp, to whom a copy of this report was provided via email. An email read receipt confirms the documents were received by Arp.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20230905110217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE LA JOLLA
FACILITY NUMBER: 374604562
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
87507(f)
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87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.

This requirement was not met as evidenced by:
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Administrator agreed to modify the private pal agreement and submit a copy to the LPA by 3/28/2025.
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Based on review of documents and interviews, the Licensee did not ensure one on one care was provided to residents as agreed, which posed a potential health, safety, 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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6