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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604562
Report Date: 04/21/2023
Date Signed: 04/21/2023 12:42:45 PM


Document Has Been Signed on 04/21/2023 12:42 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: 95DATE:
04/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Director of Resident Care Services Zachary StriplinTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by and identified himself to Concierge Thea Koulouras. LPA then met and discussed the purpose of the visit with Director of Resident Care Services Zachary Striplin, RN.

Today's visit was in response to an LIC624 Incident Report (received on 03/20/2023) and to an LIC624A Death Report (received 03/22/2023), both involving Resident #1 (R1), which licensee self-submitted to the CCLD San Diego Regional Office. [See LIC811 Confidential Names List for a description of R1.] Per these reports, R1 had an unwitnessed fall on 03/15/2023, combined with chest pains. R1 was transported via 911 to the hospital, where they passed away later that same morning.



During today’s visit, LPA briefly toured the facility, reviewed relevant records, and interviewed pertinent staff.

Per their official Death Certificate, R1's cause of death was "hypertensive and atherosclerotic cardiovascular disease." There was no indication of R1's fall being a contributing factor to their death. The evidence shows that staff timely responded to and arranged medical care for R1's cardiac symptoms.

No deficiencies were identified or cited during today's visit.

An exit interview was conducted with Striplin, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
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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