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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202350
Report Date: 07/22/2025
Date Signed: 07/22/2025 12:24:47 PM

Substantiated


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
03/24/2025 and conducted by Evaluator Christine Kabariti
COMPLAINT CONTROL NUMBER: 26-AS-20250324143221
FACILITY NAME:BELMONT VILLAGE SAN JOSEFACILITY NUMBER:
435202350
ADMINISTRATOR:RACHEL BROWNFACILITY TYPE:
740
ADDRESS:500 S WINCHESTER BLVDTELEPHONE:
(408) 984-4767
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:150CENSUS: DATE:
07/22/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Rachel BrownTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff inappropriately restrained a resident while in care
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 03/24/2025, the Department received the complaint. On 04/03/2025, the initial complaint investigation was conducted. The following documents were obtained to include a resident’s physician’s report, service plan, progress notes, resident roster and police report.

It was alleged that on 10/27/2024 a staff member (S1) held the wrist down of a resident (R1) for about 15 seconds in order to “check his/her strength”. It was reported that R1 attempted to get his/her wrist away from S1 but was unable to do so. The incident was observed by a staff (S2) who stopped the incident. R1 did not sustain any injuries and did not recall the event due to his/her diagnosis of a neurological condition. Page 1 of 3.
Substantiated
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 3
Control Number 26-AS-20250324143221
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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On 11/06/2024, the Department conducted a case management visit to follow-up on this incident after receiving a self-reported SOC-341 from the facility. See case management on 11/06/2024. During this visit, R1 was interviewed and was unable to recall the incident occurring. R1’s family member was informed of the incident. The Executive Director (ED) stated that based on their internal investigation, S1 stated that he/she does this with R1 in a joking way where sometimes S1 would test R1’s strength. At the time of the interaction, R1 was not participating in the joke and seemed startled. S1 was terminated following the incident for inappropriate behavior with the resident. The local police department was notified and responded to the incident on 10/27/2024. Based on record review, R1 did not sustain any injuries and did not recall the event. The police obtained information of S1 and was identified and outstanding at time of the event.

On 03/24/2025, the Department received a cross-report of the same incident and generated a complaint investigation.

On 04/03/2025, 4 additional staff members were interviewed for the complaint investigation. Based on staff interview, it was stated that R1 was restrained by S1 and verbally challenged to attempt to raise his/her arm as an exhibition of strength. When the Executive Director (ED) interviewed S1 following the incident, S1 stated the incident was only a playful interaction with R1. The incident was witnessed by a staff (S2) who immediately stopped the interaction.

Based on interview with S2, it was stated that S1 approached R1 from behind and held R1’s wrist on the side of his/her chair restricting R1’s movement. S2 stated that R1 had a distress look on his/her face during the interaction. S2 stated to have immediately called out S1’s name who immediately released R1’s wrist and reported to S2. S2 reminded S1 to not interact with the residents in that manner and to be careful of his/her action. The observation was then reported to management.

The Department has investigated the above allegation. Based on interview and record review the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report and appeal rights were provided. Page 2 of 2.
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 3
Control Number 26-AS-20250324143221
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2025
Section Cited
CCR
87468.1(a)(1)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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Licensee immediately conducted an internal investigation after being notified of the incident and terminated S1. Licensee completes annual and in-service training on personal rights.
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Based interview and record review, the licensee did not ensure that resident (R1) was accorded dignity in his/her relationship with S1, as S1 was observed to restrain R1’s wrist down which poses an immediate health, safety, and personal rights risk to person in care.
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Copies of the training records was provided to LPA Kabariti.

Deficiency was cleared during visit.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC9099 (FAS) - (06/04)
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