374604562-7-1-2026-08-AS-LTEZ-DWMTX2-20260804150625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604562
Report Date: 07/01/2026
Date Signed: 07/01/2026 02:46:13 PM

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
06/04/2026 and conducted by Evaluator Janet Ngallo

COMPLAINT CONTROL NUMBER: 08-AS-20260604144634

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: 194	DATE:	07/01/2026
		UNANNOUNCED	TIME BEGAN:	12:01 PM
MET WITH:	Executive Director James Arp, Director of Resident Care Cat Tomboc		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff neglect resulting in resident developing pressure injury in care.
Staff are not assisting resident with obtaining medical care.

INVESTIGATION FINDINGS:

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

On 06/04/2026, it was alleged that staff neglect resulted in resident(R1) developing pressure injury in care, and that staff are not assisting resident with obtaining medical care. The department's investigation consisted of interviews, LPA observations, 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: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

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-20260604144634

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: 07/01/2026

NARRATIVE

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[Cont. from LIC 9099-C]

Based on interviews, observations, and records review, the preponderance of evidence standard has not been met, therefore the above allegations are 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: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20260604144634

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: 07/01/2026

NARRATIVE

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[Cont. from LIC 9099]

Regarding both allegations, interviews revealed that R1 is receiving hospice services through a hospice agency, which provides routine wound care, nursing visits, and supplies. Interviews confirmed that the facility coordinates with hospice regularly, notifies hospice when skin changes are observed, and follows hospice care instructions. Staff stated that R1 receives frequent monitoring, assistance with ADLs, and repositioning. Interviews stated that the wound observed on R1 was identified by the hospice agency as a Kennedy ulcer, which develops rapidly during end-of-life decline. Caregiver staff who had worked with R1 regularly, reported that earlier minor skin issues resolved with cream treatments, but then they observed a wound with odor that quickly became larger despite the frequent repositioning. Staff stated that the observation was reported, and that hospice assessed the wound, identified and referred to it as a Kennedy ulcer, and provided regular dressing changes and wound management more than three times a week during the past two months. Staff reported that R1 required two-person assistance for repositioning, was kept clean, and that staff notified management staff if there were any changes.

Interviews with the hospice agency that provided care for R1 reported observing the wound during routine visits and confirmed the hospice team was actively treating it. The outside source(OS1) stated the wound continued to enlarge despite treatment due to R1’s overall decline.

A welfare check conducted by outside authorities prior to the initial investigation resulted in no concerns regarding R1’s condition or care. LPA Persaud observed R1 during an initial visit. R1 was in bed, and staff assisted with gentle repositioning and removed R1's wound dressing for LPA observation. The sacral wound appeared smaller and appropriately managed compared to the photo submitted with the complaint. No indicators of untreated infection or distress from R1 were observed.

Records review of R1's reassessment dated 05/10/2026 documented earlier redness to R1's buttock and that hospice was notified immediately on 05/06/2026 when an open sacral area was noted. Hospice orders included foam dressing, metronidazole application, frequent repositioning, and skin protection. Hospice progress notes consistently documented wound care for a Kennedy ulcer, ongoing monitoring, dressing changes, and progressive decline appropriate to hospice status. Hospice visit logs throughout May 2026 repeatedly identified the wound as a Kennedy ulcer with no infection present. R1’s medical assessment (LIC 602) indicated wound/skin management needs, non-ambulatory status, and hospice enrollment.

[Cont. on LIC 9099-C pg.1]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

LIC9099 (FAS) - (06/04)

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