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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604562
Report Date: 12/18/2025
Date Signed: 12/18/2025 05:27:16 PM

Document Has Been Signed on 12/18/2025 05:27 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: 187DATE:
12/18/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Executive Director James ArpTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) James Arp. Note, LPA did step out for lunch from 12pm-1pm.

Community Care Licensing received an Incident Report on 12/05/25 in which it was reported that Resident #1 (R1) had eloped from the facility during the night and had been located by police approximately a block away from the facility, and taken to the hospital. Per the report, R1 sustained a laceration to the head, which was treated at the hospital. R1's responsible party and primary care physician were notified of the incident. LPA had also received a verbal report via phone call by ED Arp same day, where additional details regarding the incident were shared. Per the verbal report, R1 had a Diagnosis of Dementia and that exterior door alarms had failed, thus not notifying staff. Additionally, per ED Arp, the security guard that was supposed to be at the front entrance where R1 passed as they left the property was not at their post, and thus did not see R1 wander away either.

During today's visit, LPA conducted a health and safety visit with R1 and provided consultation with ED Arp. The facility has moved R1 to the secured Memory Care unit post hospital discharge. The facility is working on updating/repairing their exterior door alarm systems and adding additional alarms to them. Additionally, the facility has increased staff presence at the front entrance to ensure someone is present at all times. The facility plans to implement trackable devices for at-risk residents for wandering/elopement in the coming months.

[Continued on LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2025
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: 12/18/2025
NARRATIVE
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[Continued from LIC 809]

Per review of R1's physician's report dated from May 2023, though R1 had no noted wandering/exit seeking behaviors, they were noted to be unable to leave the facility unassisted. Per review of R1's care assessment and service plan from November 2025, R1 required escort assistance to meals and activities due to their memory, but needed no assistance with guidance and redirection. Interviews with staff and R1's responsible party corroborated that R1 did not exhibit wandering behaviors prior to this incident. Interviews also corroborated that R1 received multiple staples to treat the laceration to their head sustained during their elopement.

A type A deficiency was cited per Title 22 regulations and are noted on the attached LIC 809D. The citation is issued for the facility having been unable to meet the needs of R1 to ensure they did not leave the facility unassisted. As this is a violation that resulted in an injury to an individual in care, a Zero Tolerance Violation Civil Penalty is being assessed in the total amount of $500.00 and details are noted on the attached LIC 421IM. Additional Civil Penalties are under review by the Community Care Licensing (CCL) Department and may be assessed at a later date.

A Technical Violation (TV) was also issued due to an accessible body of water located in the outdoor patio area of the ground floor. LPA explained the risks of residents who require additional supervision being around such fixtures.

One deficiency was cited during the visit and one TV. An exit interview was conducted with Executive Director Arp 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: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2025 05:27 PM - It Cannot Be Edited


Created By: Arian Golbakhsh On 12/18/2025 at 03:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BELMONT VILLAGE LA JOLLA
FACILITY NUMBER: 374604562

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2025
Section Cited
CCR
87468.2(a)(4)

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87468.2: In addition to the rights listed in Section 87468.1 [...] residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs
This requirment is not met as evidenced by:
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R1 has been moved to the secured memory care unit. Licensee will submit a plan of operations in measures/changes made to mitigate elopement risk at the facility. Licensee will submit this to LPA by POC due date.
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Based on file review and interviews, the Licensee did not ensure R1 was unable to leave the facility unassisted, resulting in elopment causing serious bodily injury to R1, posing an immediate health and safety risk to 1 out of 187 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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
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