374604562-6-4-2026-08-AS-APAO-DW86JG-20260721205105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604562
Report Date: 06/04/2026
Date Signed: 06/04/2026 11:56:47 AM

Unsubstantiated

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
06/01/2026 and conducted by Evaluator Janet Ngallo

COMPLAINT CONTROL NUMBER: 08-AS-20260601111215

FACILITY NAME:	BELMONT VILLAGE LA JOLLA		FACILITY NUMBER:	374604562
ADMINISTRATOR:	ARP, JAMES		FACILITY TYPE:	740
ADDRESS:	3880 NOBEL DRIVE		TELEPHONE:	(858) 450-2500
CITY:	LA JOLLA	STATE: CA	ZIP CODE:	92037
CAPACITY:	220	CENSUS: 195	DATE:	06/04/2026
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Executive Director James Arp		TIME COMPLETED:	12:05 PM

ALLEGATION(S):

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Staff did not assist resident with transfer, resulting in resident experiencing unwitnessed fall.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegation. LPA identified themselves and met with Executive Director James Arp to discuss the purpose of the visit and elements of the complaint.

On 06/01/2026, it was alleged that staff did not assist a resident(R1) with transfer, resulting in R1 experiencing an unwitnessed fall. The department's investigation consisted of interviews and records review.

[Cont. on LIC 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20260601111215

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: 06/04/2026

NARRATIVE

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[Cont. from LIC 9099]

Regarding the allegation, interviews consistently reported that R1 requires assistance with most activities of daily living, including assistance with transfers, and that staff regularly prompt R1 to use their call light pendant for help before getting out of bed. Interviews consistently stated that R1 sometimes attempts to transfer independently despite frequent reminders to wait for assistance, and will be successful with ambulating and transferring independently most times. Staff reported that on the night of the fall, R1 did not activate her pendant and yelled for assistance where staff was on the floor and able to hear and assist R1 promptly. Interviews also reported that staff conduct routine wellness checks on R1 every fifteen(15) to thirty(30) minutes.

Records review of R1’s assessment and service plan dated 03/27/2026 revealed that R1 requires staff assistance with ADLs, assistance to the bathroom, frequent room checks, fall prevention measures, and encouragement to use the pendant for assistance. Records also documented recent confusion, hallucinations, and mobility decline associated with medical conditions. The incident report submitted to the Department reported that R1 had an unwitnessed fall in their bedroom and stated they tripped and lost balance. EMS transport was initiated per protocol, and R1 was admitted to the hospital with altered mental status.

Based on interviews and records review, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. An exit interview was conducted with Executive Director James Arp and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

LIC9099 (FAS) - (06/04)

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