435202350-12-4-2025-26-AS-RMAO-DQNV4W-20260125150702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202350
Report Date: 12/04/2025
Date Signed: 12/04/2025 01:44:22 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
09/03/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20250903112859

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: 106	DATE:	12/04/2025
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Administrator Rachel Brown		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff hit resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Rachel Brown.

On September 3, 2025 the Department received a complaint alleging Staff hit resident. It has been alleged staff S1 hit resident R1.

On September 9, 2025, LPA Monter conducted the initial complaint investigation visit. LPA attempted to interview resident R1. R1 stated he/she declined to be interviewed.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

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 26-AS-20250903112859

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: 12/04/2025

NARRATIVE

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LPA interviewed staff S2-S4. S2 stated on September 1, 2025, he/she was preparing breakfast in the kitchen area of the dining room. S2 stated he/she noticed that they needed another meal made because one was missing and he/she asked S1 to contact the kitchen. S2 stated R1 was sitting on a wheel chair close to the telephone, S1 moved R1. S2 stated he/she observed R1 elbow staff S1 and saw R1 roll his/her wheel chair back hitting against S1. S2 stated as he/she saw this, he/she saw S1 then hit R1's right forearm with his/her right hand. S2 stated it was kind of like a reaction. S2 stated he/she asked S1 why he/she did that and S1 apologized.

LPA requested S2 re-enact the hit on LPA's arm. S2's re-enactment was a slap, open handed, swinging the forearm downwards. S2 stated it made a slapping sound. S2 stated it wasn't a full swing.

Staff S3 stated the day of the event, he/she was in his/her office. S3 stated S1 arrived to his/her office. S3 stated staff S1 said, he/she did hit R1. S1 said he/she tried to make a call and R1 hit S1. S1 stated he/she tried to get R1 to stop, and he/she reacted.

Staff S4 stated he/she did work on September 1, 2025, but doesn’t remember where he/she was when the incident occurred. S4 stated he/she didn’t see the incident take place.

On September 1, 2025, local law enforcement (LLE) interviewed resident R1, who did not recall the incident and had no complaint of pain. LLE did not observe any visible injury on R1. LLE interviewed staff S3. S3 stated at approximately 12:30pm, S1 was using the phone in the dinning hall when R1 came up to S1 and hit S1 repeatedly. S1 hit R1 back with an open hand one time causing R1 to stop. S1 reported the incident to S3.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20250903112859

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: 12/04/2025

NARRATIVE

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On October 31, 2025, LPA Manuel Monter interviewed Staff S1. S1 stated the day in question, he/she was working in the memory care unit. S1 stated it was around lunch time. S1 stated there was a meal missing for a resident. S1 stated he/she needed to make a call to the kitchen to get that additional meal. S1 stated the phone is dining room next to dinning room table, directly across from the entrance doorway. S1 stated as he/she was reaching for the phone, R1 tried to hit him/her. S1 stated as he/she was being stuck, he/she redirected R1’s hand. S1 stated he/she had not been hit by R1 before and was shocked. S1 stated he/she didn’t hit R1, and he/she only put R1’s hand down. S1 stated he/she thinks, he/she may have accidentally scared R1 when he/she reached for the phone. S1 stated he/she doesn’t remember which hand he/she put down. S1 stated after putting R1’s hand down, staff S2 told him/her not to hit R1. S1 stated he/she then walked away. S1 stated he/she told the staff S3, that he/she had hit R1. S1 stated he/she had used the wrong term when she told S3 that he/she hit R1. S1 reiterated that he/she didn’t hit R1 and only placed R1’s hand down.

On November 20, 2025, LPA Manuel Monter interviewed staff S2-S9. 8 Out of 8 Staff (S2-S9) interviewed stated prior to the event that occurred between R1 and S1 on September 1, 2025, S1 was a kind person who has not had any issues with families, other staff or residents. Staff S3-S5 & S7-S9 stated they were working at the facility on September 1, 2025, but did not witness the incident between R1 and S1. Staff S6 stated he/she was not in the facility when the alleged incident occurred and did not witness the event.

LPA Manuel Monter interviewed ADM. ADM stated that Staff S1 is a mild mannered person. ADM stated S1 prior to the event in question, S1 has not had any issues with families, other staff or residents.

On December 1, 2025, LPA Manuel Monter interviewed Staff S10-S12. Staff S10-S12 stated they were working at the facility when the alleged incident occurred on September 1, 2025. Staff S10 and S11 stated they were not in the dinning area and did not observe the event. 3 Out of 3 staff (S10-S12) stated S1 has not had any issues with staff, residents or families.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250903112859

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: 12/04/2025

NARRATIVE

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Staff S12 stated he/she was in the dinning room, located close to the entrance, when the alleged incident occurred. S12 stated he/she was serving food, he/she heard R1 was hitting S1. S12 stated he/she heard staff S1 say, “don’t hit me, don’t hit me.” S12 stated when he/she heard this, he/she turned around to see what was happening. S12 stated as he/she turned, he/she saw S1 moving R1’s wheel chair back. S12 stated he/she didn’t’ see anything else. S12 stated S2 went and asked what had happened. S12 stated S1, had said, R1 was hitting him/her. S12 stated, S2 responded that he/she would need to report it. S12 stated he/she did not observe staff S1 hit or touch R1.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025

LIC9099 (FAS) - (06/04)

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