Belmont Guests Retreat I

Type of visit: Required - 1 Year

On February 19, 2026, at 8:30 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Administrator (ADMIN) Elizabeth Mullins. LPA Kim explained the purpose of the visit to ADMIN Mullins. The facility is licensed to operate for six (6) nonambulatory residents, of which 1 may be bedridden, and has a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: one (1) staff bedroom, five (5) resident bedrooms, three (3) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with ADMIN Mullins. There were no bodies of water or obstructions in the facility. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 115.3 degrees F to 119.1 degrees F. A comfortable temperature of 72 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food both were available and maintained properly. Emergency food, emergency water, and emergency supplies are stored in the garage. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE) in the shed in the backyard. All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-970-0247) and video teleconferencing mobile telephone dedicated to the residents both remain available. Last emergency drill was conducted on December 27, 2025, and are conducted quarterly. First aid kit is maintained and contains all the necessary elements. The facility has two (2) fire extinguisher that are charged and mounted in the resident hallway, and were last inspected on January 26, 2026. Certificate of Liability of Insurance is effective from April 9, 2025 to April 9, 2026. LPA Kim conducted an audit of resident files (R1-R2), staff files (S1-S2), and medication and medication administration record were in all in order and complete. LPA Kim conducted two (2) staff interviews. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Administrator Elizabeth Mullins.the state’s words, verbatim · CDSS document, Feb 19, 2026

Allegation investigated: Facility refused to provide refund after resident passed away.

On October 27, 2025, at 9:00 AM, Licensing Program (LPA) Edward Kim conducted an unannounced initial complaint visit at the facility. LPA Kim met with Administrator (ADMIN) Elizabeth Mullins and explained the purpose of the visit. During today's visit, LPA Kim conducted a tour of the indoor and outdoor physical plant with ADMIN Mullins. LPA Kim reviewed and obtained copies of the following records for Resident #1 (R1): Admission Agreement, Identification and Emergency Information, Physician's Report, Appraisal Needs and Services Plans, and other pertinent records. LPA reviewed and obtained the Personnel Record, Resident Roster, and other pertinent records. LPA Kim also conducted one (1) staff interview. Continued on LIC9099C Substantiated The investigation revealed the following: Allegation: Facility refused to provide refund after resident passed away It is alleged that the facility did not issue a refund to the individual or entity contractually responsible for R1 payment. The individual requested a refund for the remaining days of October. R1 passed away on October 7, 2025, and an individual for R1 removed all of their belongings on October 8, 2025. Based on an interview conducted, Staff #1 confirmed the allegation that they did not process a refund for the individual responsible for R1’s payment. S1 stated that the reason they did not issue a refund is because the Admission Agreement stated there are no refunds for the first month’s rent. S1 stated that R1 passed away on October 7, 2025, and removed personal belongings on October 8, 2025. Hospice picked up the medical equipment supplied on October 9, 2025. Based on record review, a copy of a check dated September 22, 2025, revealed a payment for R1 was made for $5500 and was received by the facility and per interview with S1, the facility will send a refund to R1’s responsible party. Based on observation, LPA verified that R1’s room was empty, and all R1’s personal property, belongings, and hospice equipment were no longer inside of the room. Based on information gathered, there is sufficient evidence to corroborate the above allegation. Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility refused to provide refund after resident passed away is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. A deficiency is being cited on the attached LIC9099D. Exit interview was conducted, and a copy of the report, LIC9099D, LIC811, and the appeal rights were provided to Administrator Elizabeth Mullins.the state’s words, verbatim · CDSS document, Oct 27, 2025 · control 22-AS-20251022110928

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5)(A) · Plan of correction due date: Nov 10, 2025

87507(g)(5)(A) Refund conditions. (A)Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. This requirement is not met evidenced by: Based on record review, interview, and observation, the licensee did not comply with the section cited above. A refund was not issued to R1’s responsible party who paid for the month of October. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 27, 2025

Plan of correction: Licensee states they will pay a refund of $3725.80 to R1’s Responsible Party who paid the October payment and will send proof of payment to CCLD via email to Edward.kim@dss.ca.gov by POC due date November 10, 2025.

Type of visit: Case Management - Deficiencies

On October 27, 2025, Licensing Program Analyst (LPA) Edward Kim conducted a case management deficiency visit unrelated to an allegation of complaint # 22-AS-20251022110928. LPA interviewed Administrator (ADMIN) Elizabeth Mullins, who stated they submitted the LIC624A for a death report through mail on October 10, 2025. Per record review, As of October 27, 2025, LPA observed on the Serious Incident Report (SIR) OCRO portal that there was no death report submitted for R1 when they passed away. There is no record of the LIC624A being received within seven days of R1's death on October 7, 2025. A deficiency was cited by Title 22 Division 8 Chapter 6. An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Elizabeth Mullins.the state’s words, verbatim · CDSS document, Oct 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Nov 10, 2025

87211 (a)(1)(A) Reporting Requirements (a)Each licensee shall furnish... A written report... submitted to the licensing agency ... within seven days of... Death of any resident from any cause regardless of where the death occurred, This requirement is not met as evidenced by: Based on record review, interview, and observation, the licensee did not comply with the section cited above. A Death Report was not submitted to CCLD Orange County Regional Office within 7 days of when R1 passed away. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 27, 2025

Plan of correction: Licensee states they will send a copy of the LIC624A Death Report to CCLD via email to edward.kim@dss.ca.gov by POC due date November 10, 2025.

Type of visit: Required - 1 Year

On February 7, 2025, at 8:20am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Administrator (AD) Elizabeth Mullins. LPA Kim explained the purpose of the visit to AD Mullins. The facility is licensed to operate for six (6) nonambulatory residents, of which 1 may be bedridden, and has a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: one (1) staff bedroom, five (5) resident bedrooms, three (3) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with AD Mullins. There were no bodies of water or obstructions in the facility. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 110.3 degrees F to 114.4 degrees F. A comfortable temperature of 72 degrees F was maintained in the facility. LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food both were available and maintained properly. Emergency food, emergency water, and emergency supplies are stored in the garage. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE) in the shed in the backyard. All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-970-0247) and video teleconferencing mobile telephone dedicated to the residents both remain available. Last emergency drill was conducted on December 30, 2024, and are conducted quarterly. First aid kit is maintained and contains all the necessary elements. The facility has two (2) fire extinguisher that are charged and mounted in the resident hallway. LPA Kim conducted an audit of resident files (R1-R2), staff files (S1-S5), and medication and medication administration record were in all in order and complete. LPA Kim conducted two (2) staff interviews. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Administrator Elizabeth Mullins.the state’s words, verbatim · CDSS document, Feb 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Licensee/Administrator (AD) Elizabeth Mullins has a current Administrators certificate that expires September 06, 2025. Belmont Guest Home I is a one-story community with six bedrooms and three bathrooms. The facility capacity is 6 and the census was 4 during today’s visit. All residents were observed in their bedroom during the visit. During the inspection, LPA Haley observed all resident bedrooms and bathrooms. All five resident bedrooms had all the requirements and were in compliance with regulation guidelines. One resident bedroom has all the necessary requirements but is unoccupied at the moment. In the resident bathrooms Hot water temperatures were measured in both bathrooms. In bathroom #1 hot water measured at 114.8 degrees Fahrenheit, and in bathroom #2 hot water measured at 116.6 degrees Fahrenheit. No hazardous items were observed in the resident bathrooms. In the hallway, right across from the main bathroom, LPA Haley observed a locked desk with resident medications. In the locked desk/cabinet next to the locked medication desk, there is a locked cabinet with staff and resident files. There was a fully charged fire extinguisher hanging on the wall next to the locked staff and resident files. Down the hallway near the second resident bathroom, a supply of clean linen was observed. Across from bathroom #2, a carbon monoxide detector was observed and right below a fully charged fire extinguisher was mounted on the wall. In the kitchen LPA Haley observed a perishable and nonperishable food supply in compliance with regulation guidelines. Knives and sharp objects are kept locked in the drawer near the sink. Continued on LIC809C Some hazardous cleaning materials were kept locked below the sink. The stove was clean and all four burners on the stover were operational. In the garage, there was a large back up supply of nonperishable food items. Two additional deep freezers with a supply of perishable food items, and two additional refrigerators with perishable food items. A back up supply of water was observed. In the garage a washer and dryer was observed along with additional cleaning supplies. The remaining items in the garage consisted of additional supplies for the facility, and storage of clothing items. In the back yard a shaded patio area and a couple chairs was observed. Six storage sheds were observed. The first shed was originally to be used for an isolation room during COVID times. The remaining 5 storage sheds are used for storage of facility supplies, and one is used for storage of tools. No bodies of water observed. Smoke detectors were observed in all resident rooms, the hallways, living room and in the dining room area. During the inspection smoke detectors were tested and were operational. One carbon monoxide detector was observed in the hallway near bathroom #2. Emergency evacuation drill will be conducted quarterly per regulation guidelines and the first evacuation drill will be scheduled in March 2024. Licensee/Administrator Elizabeth Mullins was consulted on the importance of keeping the facility organized. Administrator Mullins has a lot of supplies and was instructed to keep everything organized and to go through everything and dispose of things not needed or being used to prevent clutter. No deficiencies are being cited as a result of today’s visit. An exit interview conducted and a copy of this report was provided to Licensee/Administrator Elizabeth Mullins.the state’s words, verbatim · CDSS document, Feb 20, 2024