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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604562
Report Date: 07/25/2025
Date Signed: 07/25/2025 04:12:05 PM

Document Has Been Signed on 07/25/2025 04:12 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BELMONT VILLAGE LA JOLLAFACILITY NUMBER:
374604562
ADMINISTRATOR/
DIRECTOR:		ARP, JAMESFACILITY TYPE:
740
ADDRESS:3880 NOBEL DRIVETELEPHONE:
(858) 450-2500
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY: 220CENSUS: 171DATE:
07/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Assistant Executive Director Donetta "Donnie" Johnson and Building Manager John MillerTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Associate Executive Director (AED) Donnie Johnson. The facility's license shows a maximum capacity of 220 non-ambulatory residents, of which 100 may be bedridden. All rooms are approved for bedridden and the facility is approved for delayed egress on floors 2, 3, 4, and 5. Additionally the facility has an approved hospice waiver for 20. During today’s inspection there were 171 residents in care.
 
LPA, accompanied by AED Johnson and Building Manager John Miller, toured the interior and exterior of the facility and inspected common areas as well as a sample of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms inspected contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sinks tested on floors 4, 5, 8, 11, 14, 15, and 16 temped at 106.6, 105.2, 105, 105, 108.6, 105.2, and 106.5F, respectively. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Kitchen staff demonstrated precautions taken for dietary restrictions. Cooking, dining equipment, and utensils were present. Knives were stored in areas inaccessible to residents.
[Continued on LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2025
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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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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/25/2025
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[Continued from LIC 809]

No toxic chemicals or poisons were accessible to clients. Laundry areas were noted to be locked or if they were in use and doors opened, staff were present to monitor. Medications were labeled, as required, and stored in locked areas. Med room staff demonstrated to LPA medication administration procedures and LPA also observed med room staff pass medications to residents.

A pool exists on the premises. LPA observed the pool to have a surrounding gate per regulation and gates noted to be secured. Per interview with AED Johnson and Building Manager Miller, only staff have keys to the gates and residents who check out keys are monitored by staff while in the pool area.

Per AED Johnson, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, fire sprinkler system, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. Most recent emergency drill conducted with staff was held on 6/26/25 for the topics of earthquakes and fires. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA observed residents engaged in facility led activities, particularly in the Connections for Living and Memory Care units. Various calendars and postings throughout common areas of the facility noted various scheduled activities and events. LPA observed various staff and resident interactions throughout their visit and noted residents to be attended to quickly and treated with respect.

LPA interviewed 2 staff and 2 clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. LPA did provide a Technical Assistance for best practices on ensuring 1st Aid/CPR Certificates were current and valid.

No deficiencies were cited during the inspection. An exit interview was conducted with Associate Executive Director Johnson to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC809 (FAS) - (06/04)
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