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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604562
Report Date: 07/21/2022
Date Signed: 07/21/2022 11:01:25 AM


Document Has Been Signed on 07/21/2022 11:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



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: 0DATE:
07/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Senior Executive Director, James Arp, Senior Vice President, Douglas Armstrong, Director of Resident Care Services, Zachary Striplin, and Building Engineer, John MillerTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Sabel Martinez, conducted a scheduled Pre-licensing inspection to observe the physical plant for compliance and conduct a Component III. The San Diego Fire-Rescue Department conducted a Fire Inspection on 7/6/2022. A fire clearance was granted for total capacity of two hundred twenty (220) residents. One hundred twenty (120) residents may be non-ambulatory, and One hundred (100) may be bedridden.

The LPA was greeted by Senior Executive Director, James Arp, Senior Vice President, Douglas Armstrong, Director of Resident Care Services, Zachary Striplin, and Building Engineer, John Miller. The LPA identified himself and disclosed the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs throughout the facility to promote hand hygiene, face coverings worn by staff; hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of Personal Protective Equipment (PPE).

Additionally, the LPA observed exterior and interior passageways were free from obstructions. All of the residents’ rooms were equipped with the required furnishings. Residents' bathrooms were observed to be sanitary and operational. Common areas with an ample amount of space for scheduled and recreational activities were observed. The facility was stocked with a 2 day supply of perishable and a 7 day supply of non-perishable food items.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE LA JOLLA
FACILITY NUMBER: 374604562
VISIT DATE: 07/21/2022
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 Medication rooms, medication carts, and a pool area were observed to be locked and inaccessible to residents.

During the exit interview with Senior Executive Director, James Arp, Senior Vice President, Douglas Armstrong, the LPA discussed continuing operation requirements, record keeping, reporting requirement and physical plant compliance. The Facility is ready to be licensed pending management approval. A copy of this report along with Applicant/Appeal Rights (LIC9058 01/16) were provided to Senior Executive Director, James Arp.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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