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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202856
Report Date: 10/07/2025
Date Signed: 10/07/2025 12:10:54 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
02/03/2025 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20250203111059
FACILITY NAME:BELMONT VILLAGE LOS GATOSFACILITY NUMBER:
435202856
ADMINISTRATOR:MARTINEZ, RADHIKAFACILITY TYPE:
740
ADDRESS:5121 UNION AVENUETELEPHONE:
(408) 559-3333
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:175CENSUS: 131DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Radhika MartinezTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Staff does not ensure resident's medication is refilled.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver amended investigation findings report and met with Senior Executive Director (ED) Radhika Martinez.

On 02/03/2025, the Department received a complaint with the above allegation.

On 2/12/2025 the Department conducted an initial investigation visit. LPA interviewed ED, 4 staff and 3 residents. LPA toured the medications room and resident room.

On 8/5/2025, The complaint allegation is being reopen due to new information has been received by the Department.

Continue on LIC9099-C. Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
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 7
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
02/03/2025 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20250203111059

FACILITY NAME:BELMONT VILLAGE LOS GATOSFACILITY NUMBER:
435202856
ADMINISTRATOR:MARTINEZ, RADHIKAFACILITY TYPE:
740
ADDRESS:5121 UNION AVENUETELEPHONE:
(408) 559-3333
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:175CENSUS: 132DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Radhika MartinezTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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2
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9
Staff does not communicate with resident's responsible party in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver amended investigation finding report and met with Senior Executive Director (ED) Radhika Martinez.

On 02/03/2025, the Department received a complaint with the above allegation.

On 2/12/2025 the Department conducted an initial investigation visit. LPA interviewed ED, 4 staff and 3 residents. LPA toured the medications room and resident room.

On 8/5/2025, The complaint allegation is being reopen due to new information has been received by the Department.

Continue on LIC9099-C. Page 1 of 3.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20250203111059
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 LOS GATOS
FACILITY NUMBER: 435202856
VISIT DATE: 10/07/2025
NARRATIVE
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Staff does not communicate with resident's responsible party in a timely manner:

On 2/12/2025 and 5/1/2025, LPA interviewed Executive Director (ED) Radhika Martinez. ED stated on 1/16/2025, at 1:00AM, resident R1's family member (FM1) sent an email to ED's email address to request to meet ED at 11:00AM on 1/16/2025. ED stated he/she was sick and was off on 1/16/2025. ED stated Director of Resident Care Service (DRC) was on vacation form 12/26/2024 to 01/19/2025.

ED stated on 1/16/2025, at 11:00AM, FM1 came to the facility and wanted to meet ED. ED stated Director of Memory Care (DMC) explained to FM1 that ED was sick and was not in the facility. ED stated FM1 still requested to meet with ED. ED stated DMC notified his/her boss, Senior Vice President Ann Wood (VP) that FM wanted to meet ED. ED stated VP called R1's POA (FM2), at 12:14PM on 1/16/2025, and left message that he/she is available to talk to R1's family. ED stated on 1/16/2025 night VP confirmed with R1's, POA, FM2 to meet on 1/20/2025 at the facility. ED stated he/she met with R1's POA, FM2 and FM1 on 1/20/25, Monday, in the facility.

LPA interviewed Director of Memory Care (DMC). DMC stated on 1/16/2025, at 11:34AM, he/she received a notice from staff that R1's family member FM1 wants to meet with ED. DMC stated he/she went to meet with FM1. DMC stated he/she explained to FM1 that ED was sick and off. DMC stated he/she explained to FM1 that he/she is the on duty manger of the facility. DMC stated he/she answered FM1's questions but FM1 still requested to meet ED. DMC stated ED's boss, Senior Vice President was notified.

On 08/05/2025, LPA interviewed ED. ED stated based on the facility's chain of command, Director of Resident Care Service (DRC) is the one next to him/her but DRC was on vacation from 12/26/2024 to 1/19/2025. ED stated Director of Memory Care (DMC) is the one next to DRC.

LPA interviewed Director of Memory care (DMC). DMC stated on 1/16/2025, around 11:34AM, he/she met with R1's family member FM1. DMC stated he/she explained to FM1 that ED is sick and off, and DRC is on vacation. DMC stated he/she told FM1 that he/she is the on duty manager of the facility. DMC stated FM1 still requested to meet ED. DMC stated he/she can arrange a video conference for FM1 to meet with ED but FM1 did not agree. DMC stated ED's boss, Senior Vice President was notified.
Continue on LIC9099-C. Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20250203111059
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 LOS GATOS
FACILITY NUMBER: 435202856
VISIT DATE: 10/07/2025
NARRATIVE
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LPA interviewed Senior Vice President Ann Wood (VP). VP stated on 1/16/2025, he/she received a phone call from Director of Memory Care (DMC) that FM1 wanted to see ED, but ED was sick and not in the facility. VP stated he/she called R1's family member (FM2), responsible party, POA, at 12:14PM on 1/16/2025 and left message. VP stated he/she text and talked with FM2 and confirmed to have a meeting with ED in the facility on 1/20/2025, at 11:00AM because FM2 wanted to meet with ED in person. VP stated ED met with R1's family members for about one and half hours.

Based on the interview, FM1 sent an email on 1/16/2025, at 1:00AM, and requested to meet ED at 11:00AM. ED was sick on 1/16/2025 and was not in the facility. Director of Resident Care Service (DRC) is the next one in the chain of command, but DRC was on vacation. ED's boss, Corporate Senior Vice President (VP) communicate and talked to resident R1's family member(FM2), responsible party and POA, on 1/16/2025 from 12:14PM to 4:34PM and confirmed to have in person meeting at the facility with ED on 1/20/2025, Monday, at 11:00AM. On 1/20/2025, at 11:00AM ED met with R1's family members FM1 and FM2 in person in the facility and the meeting last one and half hours.

The Department has investigated the above allegations. Based on the investigation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview conducted with Executive Director (ED). This report was provided to review and for signature. A copy of this report was provided to ED.


Page 3 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 26-AS-20250203111059
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 LOS GATOS
FACILITY NUMBER: 435202856
VISIT DATE: 10/07/2025
NARRATIVE
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Staff does not ensure resident's medication is refilled:
On 2/12/2025, LPA interviewed Senior Executive Director (ED) Radhika Martinez. ED stated the facility protocol is that the facility notifies the pharmacy for refill if resident's medication supplies is less than 7 days. ED stated the pharmacy notifies resident's doctor if resident needs refill order of medications. ED stated the pharmacy notifies the facility if resident's doctor does not respond to the refill order request. ED stated the facility staff faxed R1's medication M1 refill order request to R1's doctor on 12/30/2024, 1/1/2025, 1/7/2025 and 1/14/2025. ED stated facility staff called R1's doctor several times during R1's medication refill order requests but the facility did not receive response from R1's doctor. ED stated on 1/15/2025, the facility received R1's medication M1 refill order from R1's doctor. ED stated the facility administered R1's medication M1 to R1 starting on 1/16/2025

LPA interview Director of Resident Care Services (DRC). DRC stated the facility pharmacy will notify resident's doctor if the refill order will expire in 2 weeks. DRC stated the facility pharmacy will notify the facility if the facility pharmacy does not receive response from resident's doctor within 24 hours. DRC stated the facility notifies the facility pharmacy if resident's medication supplies is less than 7 days.

LPA interviewed Director of Memory Care (DMC). DMC stated resident R1 ran out of medication M1 on 1/13/2025, 1/14/2025, and 1/15/2025 due to R1's doctor did not respond to the mediation refill request.
LPA interviewed staff S3. S3 stated Med Techs and nurses will notify pharmacy if resident's medication supplies is less than 7 days. S3 stated pharmacy will notify resident's doctor if resident's medication refill order is needed. S3 stated Med Tech and nurse will contact resident's doctor if resident's doctor did not respond to the pharmacy.

On 5/1/2025, LPA was with ED and DRC, and called R1's doctor office, R1's doctor office confirmed that R1's doctor was off on 12/30/2025, 1/1/2025, and 1/7/2025. ED provided the evidence that the facility faxed R1's medication M1 refill request to R1's doctor office on 12/30/2024, 1/1/2025, 1/7/2025 and 1/14/2025.
Based on the review R1's MAR, R1's medication R1 was missing on 1/13/2025 evening, 1/14/2025, and 1/15/2025. Medication M1 was administered to R1 starting 1/16/2025.

Based on the interview and record reviewed, R1's ran out medication M1 because R1's medication M1 refill order expired and R1's doctor did not respond to the facility pharmacy's request for R1's medication M1 refill order. Continue on LIC9099-C. Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20250203111059
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 LOS GATOS
FACILITY NUMBER: 435202856
VISIT DATE: 10/07/2025
NARRATIVE
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On 8/8/2025 and 8/13/2025, LPA interviewed 2 facility nurses. 2 out of 2 nurses stated, from 12/20/2024 to 1/16/2025, they faxed to R1's doctor office around 3 times of the medication M1 refill order request but cannot remember the exact dates. Both stated they called R1's doctor office around 3 times but cannot remember the exact dates. Both stated they left messages or talked to the doctor office medical assist. Both stated the medical assist stated he/she will notify doctor for the refill order.

LPA interviewed 9 Med Techs. 1 out of 9 stated he/she faxed R1's medication M1 refill order request to doctor office. 8 out of 9 Med Tech stated they cannot remember if they faxed the refill order request to the doctor office. 9 of 9 Med Techs stated they cannot remember if they called the doctor office. 3 out of 9 Med Techs stated they called the pharmacy for R1's Med Tech refill order request.

On 8/13/2025, LPA interviewed ED. ED stated R1's medication M1 refill order button of the E MAR system was clicked on 12/20/2025. ED stated the alert on the E MAR system was on until 1/16/2025. ED stated previous Wellness coordinator called R1's doctor office a few times. ED stated previous Wellness Coordinator left the job on 7/9/2025. ED provided the information that the pharmacy faxed to R1's doctor office 10 times for medication refill request but did not call the doctor office.

The facility faxed the refill order request several times but did not communicate with R1's doctor office to ensure R1 to obtain medication M1. R1's missing medication M1 is a prescription medication is used to reduce the risk of stoke and blood clots. M1 is prescribed by R1's doctor for daily. The facility did not notify R1's responsible party to help to find a solution for R1's medication M1. The facility did not find a solution from the clinic/hospital of R1's doctor for R1's medication M1.

Based on the review of R1's MAR, let R1 missed medication M1 for 1/13/25 evening, 1/14/25 morning and evening, 1/15/25 morning and evening and 1/16/25 morning which posed an immediate health risk to resident R1.

The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.
Citations noted today. Please see LIC9099-D. Exit interview was conducted with ED. A copy of the report was provide to ED. Page 3 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Citations on this Visit Report are Under Appeal!

Control Number 26-AS-20250203111059
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 LOS GATOS
FACILITY NUMBER: 435202856
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
10/08/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs

This requirement is not met as evidenced by:
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Executive Director stated the facility will conduct a medication administration staff training. Executive Director will submit the Plan of Correction by POC due date, and submit completion log of staff training log to the Department.
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Based on record review and interview resident R1's prescription medication M1 was not administered to R1 by Med Tech On 1/13/25, 1/14/25, 1/15/25 and 1/16/25 for 4 days due to without doctor refill order which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7