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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604562
Report Date: 01/29/2025
Date Signed: 01/29/2025 01:46:17 PM

Document Has Been Signed on 01/29/2025 01:46 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: 220TOTAL ENROLLED CHILDREN: 0CENSUS: 153DATE:
01/29/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Executive Director James Arp.TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management - Incident visit. The LPA introduced himself and discussed the purpose of the visit with Executive Director James Arp. Nursing Director Cat Tomboc and Assistant Executive Director Donnie Johnson assisted the LPA during the visit.

Today's visit was in response to an LIC624A Death Report, which the licensee self submitted to the CCLD San Diego Regional Office (received on 1/28/2025). [See LIC 811 Confidential Names List for a description of Resident # 1 (R1).] During today’s visit, the LPA conducted a tour of the facility, conducted interviews, and collected pertinent records. A death certificate for R1 was also requested during the visit.

No immediate health and safety concerns were observed during today's visit and no deficiencies were cited.

An exit interview was conducted with Johnson, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058), were provided.

Lizzette TellezTELEPHONE: (619) -76-2351
Sabel MartinezTELEPHONE: (619) 767-2301
DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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