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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604562
Report Date: 10/06/2022
Date Signed: 10/06/2022 01:05:14 PM


Document Has Been Signed on 10/06/2022 01:05 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
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: 51DATE:
10/06/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Director of Residential Care Services, Zachary StriplingTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Post-Licensing Visit. The facility file was reviewed prior to the visit. The LPA identified himself, and discussed the purpose of the visit with Director of Residential Care Services, Zachary Stripling.

During today’s visit, the LPA conducted a tour of the facility and observed the residents in care. In accordance with the Department’s Infection Control program, the LPA provided technical assistance, observed, and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, testing, vaccination, screening protocols, and the use of personal protective equipment.

No deficiencies were cited on this date. An exit interview was conducted with Director of Residential Care Services, Zachary Stripling, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via electronic mail. An electronic mail read receipt confirms the documents were received by the Director of Residential Care Services.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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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