435202350-7-22-2025-26-AS-MPAA-DKRSY9-20250821141709

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202350
Report Date: 07/22/2025
Date Signed: 07/22/2025 12:25:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2025 and conducted by Evaluator Christine Kabariti

COMPLAINT CONTROL NUMBER: 26-AS-20250311090818

FACILITY NAME:	BELMONT VILLAGE SAN JOSE		FACILITY NUMBER:	435202350
ADMINISTRATOR:	RACHEL BROWN		FACILITY TYPE:	740
ADDRESS:	500 S WINCHESTER BLVD		TELEPHONE:	(408) 984-4767
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	150	CENSUS:	DATE:	07/22/2025
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Rachel Brown		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Facility staff had inappropriate behavior with a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegation. LPA met with Executive Director, Rachel Brown.

On 03/11/2025, the Department received the complaint. On 03/12/2025, the initial complaint investigation was conducted. Documents were obtained to include 5 residents physician's report, service plan, progress notes from February - March 2025, resident roster, staff schedule, and police report.

It was alleged that a staff had inappropriate behavior with a resident (R1).

Another resident (R2) was the first person to have reported the information to the staff. R2 reported that a staff was having inappropriate behavior with R1. R2 could not provide a name of the staff who had inappropriate behavior with R1 but provided a description of the staff. R2 states that the inappropriate behavior was consensual per R1. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 26-AS-20250311090818

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE SAN JOSE	FACILITY NUMBER: 435202350
	VISIT DATE: 07/22/2025

NARRATIVE

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Based on review of the police report, the report was written for information purposes. It’s indicated that R1 stated to have been kissing a staff member, but the kissing was consensual. R1 did not remember the staff member’s name. The facility’s Executive Director advised that R1 suffers from a neurocognitive disorder but can still make decisions for him/herself.

Based on the description that was provided of the staff member, it did not match any of the facility staff members on site.

R1 was interviewed. Based on interview, R1 made inconsistent statements to the Department, local police officers and facility staff regarding the alleged incident that was reported by R2.

The review of records shows that R1 has a diagnosis of a neurocognitive disorder and history of forgetfulness.

Facility staff were interviewed. Based on interview, there were no facility staff who fit the description that was provided by R2.

7 out of 7 staff members interviewed denied the observation of any staff conducting inappropriate behavior with any resident, including R1.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the allegation did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report was provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2