Belmont Village Los Gatos

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Radhika Martinez. The purpose of the visit was to address medication errors reported by the facility via Unusual Incident/Injury Report (IR) that occurred on 08/26/2026, 05/05/2026, and 03/09/2026. On 08/26/2026, Staff S1 provided an incorrect medication to resident R1. S1 did not scan the medication or use the medication laptop and gave R1 medication M1 instead of M2. On 05/05/2026, staff assisted in the administration of an extra dosage of medication M3 to resident R2. R2 had taken M3 earlier that day, but staff did not record R2’s earlier administration of M3, and gave R2 an additional dosage of M3. On 03/09/2026, staff provided R3 additional dosages of M4 and M5. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. An immediate civil penalty of $250 is being assessed today for a repeat violation. See LIC421FC for more information. This report was reviewed with Administrator Radhika Martinez and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 3, 2026

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Licensee did not ensure that staff had the competency necessary to meet resident needs, including providing residents R1-R3 with the assistance in administering the correct medications, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Licensee agrees to submit a plan of correction to the department by 09/03/2026 stating how the licensee will ensure that staff receive in-service training on assisting residents with the self-administered medications. Once training is completed, the licensee shall submit copies of staff training logs, including names of staff trained, training dates, training topics, and names and qualifications of trainers, to the department.

Allegation investigated: Staff inappropriately assisted resident with a shower

When the department received the complaint, it was alleged that a staff inappropriately assisted R1 with a shower by lathering up R1 on or around 04/01/2026. On 04/10/2026, the department obtained copies of R1’s charting notes. According to R1’s charting notes, R1 refused a shower on 04/01/2026. R1 received seven showers between the dates of 03/14/2026 through 03/28/2026 by six different female staff. On 04/10/2026, the department obtained a copy of R1’s Resident Assessment and Service Plan. R1’s Resident Assessment and Service Plan states two staff provide stand-by assistance to R1 with showering, including assisting R1 in and out of the shower. R1’s Resident Assessment and Service Plan states R1 does not require hands-on care while showering and is able to shower independently. See LIC9099-C page for more information. Page 1 of 2. Unfounded On 05/04/2026, the department obtained a copy of the police report made when police officers arrived in response to the alleged sexual abuse of R1. The police report states police arrived at the facility on 04/02/2026. The police report states a police officer interviewed R1, who stated R1 did not recall any incident in which staff made R1 feel uncomfortable or were taking advantage of him/her. The police report states during the police officer’s visit, Administrator Radhika Martinez was unable to identify any staff who met the description of the staff suspected of abusing R1. On 04/23/2026, a department investigator interviewed R1. During interview, R1 stated staff help him/her with showers. R1 states he/she showers once per day and one to two staff assist R1 with soap application. When asked if anything unusual occurred in the shower, R1 stated something unusual did occur but he/she did not know the specific date when the incident occurred. R1 stated the incident occurred “a couple months ago in the morning.” R1 stated he/she did not know which staff helped him/her, but it was “one or two staff.” On 06/24/2026, LPA Marrufo interviewed staff S1-S4 and Jeeteeh Gigliotti, Director of Residential Care Services. S1 stated he/she showered R1 last month and only provides stand-by assistance to R1 during showers. S2 stated that his/her manager, Director of Residential Care Services Jeeteeh Gigliotti, recently instructed the staff not to provide hands-on assistance to R1 in the shower. S2 stated that prior to the recent instructions from his/her manager, S2 would provide hands-on lathering assistance to R1 on the parts of R1’s body that R1 could not independently reach, such as his/her back and back of legs. S3 stated to have not provided hands-on care to R1. S4 stated to have not provided showering assistance to R1. Jeeteeh Gigliotti, Director of Residential Care Services stated staff do not provide hands-on care during showers to R1 except for times when R1 is unable to lather himself/herself, such as when R1 is attempting to lather his/her back. This agency has investigated the complaint allegation listed. Based on interviews and review of records, the department has found that the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report was reviewed with Jeeteeh Gigliotti and a copy of this report was provided. Page 2 of 2. END REPORT.the state’s words, verbatim · CDSS document, Jun 24, 2026 · control 26-AS-20260409143500

Allegation investigated: Staff sexually abused resident

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Jeeteeh Gigliotti, Director of Resident Care Services. On 04/09/2026, the department received a complaint with the above allegation. On 04/10/2026, LPA Marrufo conducted an initial complaint investigation visit. When the department received the complaint, it was alleged that on or around 04/02/2026, a staff put a condom over her fingers and digitally penetrated resident R1’s anus while the staff was giving R1 a shower. The staff was described as a Hispanic female around age 40. The name of the staff was not provided. On 04/10/2026, the department obtained copies of R1’s charting notes. According to R1’s charting notes, R1 refused a shower on 04/01/2026. R1 received seven showers between the dates of 03/14/2026 through 03/28/2026 by six different female staff. See LIC9099-C page for more information. Page 1 of 2. Unfounded On 04/23/2026, a department investigator interviewed R1. During interview, R1 was unable to provide any information about the alleged incident. On 05/04/2026, the department obtained a copy of the police report made when police officers arrived in response to the alleged sexual abuse of R1. The police report states police arrived at the facility on 04/02/2026. The police report states a police officer interviewed R1, who stated R1 did not recall any incident in which staff made R1 feel uncomfortable or were taking advantage of him/her. The police report states during the police officer’s visit, Administrator Radhika Martinez was unable to identify any staff who met the description of the staff suspected of abusing R1. On 04/02/2026, the facility submitted an Unusual Incident/Injury Report (IR). The IR states that on 04/02/2026, a facility nurse observed R1 and did not find any injuries. This agency has investigated the complaint allegation listed. Based on interviews and review of records, the department has found that the complaint allegation is unfounded, meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. This report was reviewed with Jeeteeh Gigliotti and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 26-AS-20260409143500

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 3/17/2026, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Director of Resident Care Services Jeeteeh Gigliotti. LPA explained the purpose of the visit. LPA toured the facility including a random sample of resident rooms, common areas, activity rooms. LPA observed some residents were at different activity rooms. Care staff were prepping residents for St. Patrick's luncheon. While touring the facility it was observed that the temperature was at 74 deg F. Hot water was also tested in the resident rooms and the temperature was at 110 deg F. All personal belongings are intact inside residents rooms. Facility has sprinkler system. All fire extinguishers have been checked and current. Facility has evacuation chairs in stair wells. Resident bedrooms and bathrooms were observed to be in good repair. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are done every month. Ten resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Centrally stored medication records are updated. Residents are brought to medication rooms where medications are administered. LPA received the following documents Staff Schedule, LIC308, LIC610E & Certificate of Liability Insurance. No deficiencies are cited at this time. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Mar 17, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (ADM) Radhika Martinez. The purpose of the visit was to follow up on two incidents reported by the facility via Unusual Incident/Injury Report (IR). The first IR was submitted on 02/20/2026 and stated that on 02/20/2026, resident R1 exited the facility via a stairwell exit door. R1 was wearing a bracelet that allowed staff to locate him/her. The bracelet indicated that R1 was about a block away from the facility. Facility staff located R1 and escorted R1 back to the facility. During visit on 03/13/2026, LPA Marrufo interviewed Administrator (ADM) Radhika Martinez. ADM stated that R1 lives in the Assisted Living portion of the facility. ADM stated that during the incident, staff were alerted that an exit door had been used and immediately conducted a head count of the residents. ADM stated staff realized after the head count that R1 was missing from the facility and continued to search for R1 within the facility instead of alerting management. ADM stated management staff later used a mobile application that identified the location of R1’s bracelet. R1 was found about a block away from the facility. ADM stated that staff have been trained in-service to immediately utilize the mobile application that identifies the residents’ locations using their bracelets. See LIC809-C page for more information. Page 1 of 2. During visit on 03/13/2026, LPA Marrufo obtained a copy of R1’s Physician’s Report. The Cognitive Conditions section of R1’s Physician’s Report states it is “unknown at this time” if R1 has Mild Cognitive Impairment and “unknown at this time” if R1 has Dementia/Major Neurocognitive Disorder. The Physician’s Report states that if R1 had dementia, R1 does not require supervision when leaving the property due to dementia or cognitive decline. R1’s Physician’s Report states R1 does not have disorientation, unsafe wandering, elopement, or sundowning behavior. The second IR was submitted on 12/12/2025 about an incident that occurred on 12/09/2025 involving staff S1 giving R2 medications M1-M6, which belong to R3. S1 stated R2 and R3 have a similar physical appearance and S1 mistook R2 for R3. Facility staff informed R2’s physician and family and sent R2 to the hospital as a precaution. During visit, ADM stated that every resident’s Medication Administration Record (MAR) has a photograph of the resident. ADM stated to have trained staff to verify the identity of the resident by using the photograph in the resident’s MAR and by asking the resident for his or her name prior to assisting a resident with administering medications. ADM stated that S1 checked R2’s photograph and asked R2 to verify his/her name, but R2 did not respond. ADM stated staff have been trained to ask another staff to verify the resident’s identity if the resident does not respond to a staff member’s request to verify his/her name. On 03/13/2026, LPA Marrufo obtained a copy of R2’s Physician’s Report, which states R2 is not able to administer his/her own prescription medications. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. An Advisory Note was issued. See LIC9102 for more information. This report was reviewed with Administrator Radhika Martinez and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Mar 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 14, 2026

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Licensee did not ensure that R2 was not given medications M1-M6, which belonged to R3, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 13, 2026

Plan of correction: Licensee agrees to submit a plan of correction by 03/14/2026 stating how the licensee will ensure that staff do not administer the wrong medication to residents, including in-service training of staff on assisting residents with the administration of medications. Once in-service training is completed, the licensee will submit copies of staff training records, including names of staff trained, training dates, training topics, and names and qualifications of trainers. **In-Service Training Conducted on 01/20/2026; Deficiency cleared during visit. **

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (AMD) Radhika Martinez. The purpose of the visit was to follow up on two incidents self-reported by the facility. The first incident was reported via Unusual Incident/Injury Report (IR) on 07/25/2025. The IR reported that on 07/22/2025, memory care resident R1 reported to R1's family member that R1 had been raped. The IR stated that R1's child reported to the facility that R1 has previously reported being kidnapped and that people are stealing from him/her. The IR stated R1's child believed R1's allegation of rape was a hallucination. During visit, LPA Marrufo interviewed staff S1-S4. Staff S1-S4 stated to have never observed anyone physically or sexually abuse R1. LPA Marrufo obtained a copy of a law enforcement incident card, which includes the case number that was also reported on the IR and is dated 07/23/2025. The incident card stated that a police report was not taken. LPA Marrufo conducted a wellness check on R1 and observed R1 to not have any bruises on his/her hands, face, or neck. R1 was dressed in clean clothing and was sitting in a wheelchair. The second incident was self-reported by the facility via SOC341 Suspected Adult/Elderly Abuse Form and Unusual Injury/Incident Report on 11/19/2025. The SOC341 stated that memory care resident R2 hit memory care resident R3 two times on the shoulder. See LIC809-C page for more information. Page 1 of 2. ADM stated during interview that staff have been instructed during staff meetings to keep R2 separated from other residents when R2 is exhibiting signs of being agitated and to immediately separate R2 from other residents if R2 begins hitting them. Staff S1-S4 stated to have been given training to keep R2 separated from other residents if he/she appears agitated and to immediately separate R2 from other residents if he/she begins hitting them. LPA Marrufo observed R2 and R3 while they were attending a live music event at the facility. LPA observed R2 and R3 sitting at separate tables. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Radhika Martinez and a copy of this report was provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Nov 20, 2025

Allegation investigated: Staff does not ensure resident's medication is refilled.

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 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. 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. 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. 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.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 26-AS-20250203111059

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 8, 2025

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: 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.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: 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.

Type of visit: POC

On 10/07/2025, Licensing Program Analyst (LPA) Steve Chang conducted an unannounced POC visit. LPA met with Senior Executive Director (ED) Radhika Martinez.. LPA explained the purpose of the visit. On 10/07/2025, the facility was cited the following type A deficiency during a complaint investigation visit for the complaint 26-AS-20250203111059. The following code sections were cited on 10/7/2025, with a POC due date of 10/8/2025: 87411(a). On 10/7/2025, LPA conducted a POC visit to clear the Type A citation. LPA received a copy of the facility's plan of corrections with the staff training. Resident R1 is still living in the facility and is fine with good care. A copy of the Letter of Deficiencies Cleared letter was provided. This report was reviewed with ED and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2025

Type of visit: Case Management - Other

Licensing Program Analyst(LPA) conducted an unannounced case management visit to deliver an amended investigation report and and met with Executive Director (ED) Radhika Martinez. This complaint control number 26-AS-20250203111059 investigation is being re-opened due to new information received by the Department. This complaint allegation is being amended after new information has been received by the Department. LPA interviewed ED and 6 staff. The allegations needs further investigation. Exit interview was conducted with ED. A copy of the report was provided to ED.the state’s words, verbatim · CDSS document, Aug 5, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Incident visit and met with Administrator (ADM) Radhika Martinez. The purpose of the visit was to respond to an Unusual Incident/Injury Report (IR) submitted to the department by the facility on 07/03/2025. The IR stated that on 07/01/2025, a visitor who is a family member of both residents R1 and R2 reported to staff that R1 grabbed R2's hand, resulting in R2's hand being scratched. R1 and R2 are married to one another. The IR states that staff separated R1 and R2 and provided first aid care to R2. The IR stated R1 will begin programming in the Memory Care unit and will be prescribed anti-anxiety medications. During visit, LPA Marrufo reviewed the Physician's Reports of R1 and R2. R1 and R2's Physicians Reports both state that neither have sundowning or wandering behaviors. R1's Physician's Report indicates R1 has a diagnosis of Mild Cognitive Impairment and R2 has a dementia diagnosis. R1's Service Plan was updated on 07/02/2025 to include programming in Day Programming. Both R1 and R2 live in Assisted Living. During visit, LPA Marrufo interviewed ADM. ADM stated that both R1 and R2 will visit their physician today and be prescribed anti-anxiety medications. The physician may also update R1's Physician's Report to include a dementia diagnosis. During visit, LPA Marrufo conducted a wellness check on both R1 and R2. No deficiencies were cited at this time as per California Code of Regulations, Title 22. This report was reviewed with Administrator Radhika Martinez and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 11, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management - incident visit and met with Senior Executive Director (ED) Radhika Martinez. The purpose of today's visit is to follow up with the case management visit on 3/19/2025 regarding inappropriate behavior. On 3/19/2025, the Department received a report that a staff (S1) had an inappropriate behavior to a resident (R1). Based on the interview with ED, ED stated this is the first incident of staff S1 regarding inappropriate behavior. ED stated there was no witness for the allegation. Based on the interview with 6 staff. 6 out of 6 staff stated they never saw staff S1 had any inappropriate or aggressive behavior. 2 out of 6 staff stated S1 is over active. Based on the interview with resident R1, R1 stated S1 did not touch his/her private area and did not kiss him/her. R1 stated he/she does not think it was a sexual abuse. R1 stated S1 was so close to him/her and grabbed his/her shoulder. R1 stated he/she is not sure if it is an issue of inappropriate behavior and not sure what is S1's intention. R1 stated that is why he/she did not report immediately. Continue on LIC809-C. Page 1 of 2. Based on the interview with R1's family member (FM), FM stated R1 told him/her on 3/17/2025 about the incident. FM stated he/she does not think it was a sexual abuse and did not file a complaint. FM stated he/she just notified ED about the incident. Based on the interview with residents, 1 out of 4 resident stated he/she does not know S1. 3 out of 4 residents stated they were not aware of S1 had sexual abuse or inappropriate behavior. 2 out of 4 residents stated they observed the behavior of S1 was over active and strange. ED stated the facility Director of Resident Care Service conducted an investigation for the allegation but did not find any evidence for the allegation. ED stated S1 was separated from the facility on 3/4/2025. Based on the investigation and interview, the Department found that the case is 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. No Citations were noted today. Exit interview was conducted with ED. The report was provided to ED for review and signature. A copy of the report was provide to ED. Page 2 of 2.the state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted a unannounced annual inspection visit, and met with Senior Executive Director (ED) Radhika Martinez. LPA checked 6 staff records (S1 - S6) and 6 resident records (R1 - R6). LPA toured the facility inside and out with ED. License, Administrator Certificate, Personal Rights posters were observed in the facility. Visiting policy was observed posted at the main entrance. The facility has 4 floors. The memory care unit is in the first floor. LPA toured the main entrance, mail box/snack room, activity room 1 & 2 in Assist Living unit, dining room in Assist Living unit, kitchen, and courtyard. LPA toured memory care unit activity room 1 & 2, dining room, and patio. LPA tested the delay opening doors in the memory unit, and they were working fine. Staff came on site immediately when the alarm sounded. The second floor has activity rooms, offices, Medication room, and Assisted living apartments. The third floor has activity rooms, theater room and assisted living unit. The forth floor has Fitness room, salon room and assisted living unit. LPA toured the Assist Living unit and Memory care unit apartments. Food menu and specialist diet list were observed posted. 2 medication rooms and medication carts were observed locked. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Knives storage and cleaning product rooms were observed locked. Room temperature was at 71 degree F, and hot water temperature was at 119 degree F in facility. the temperature of refrigerator was at 37 degree F and the temperature of the freezer was at 0 degree F. Fire extinguishers were serviced on 1/7/2025. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. 2 evacuation chairs were observed in each stair in the facility. The elevators were observed working. Public restrooms were inspected. LPA tested the bell button system and it worked fine. ED stated the last time the facility conducted the emergency and fire drill was on 2/4/2025. No citation was noted for today's inspection. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED.the state’s words, verbatim · CDSS document, Mar 26, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Incident visit and met with Senior Executive Director (ED) Radhika Martinez. On 3/19/2025, the Department received a report that a staff (S1) had an inappropriate behavior to a resident (R1). The purpose of today's visit is to obtain more information and to investigate. LPA interviewed ED, 6 staff (S2 - S7), 5 residents ( R1 - R5), and a family member (FM) of a resident. ED stated staff S1 was terminated by the facility because S1 was found sleeping while on duty. ED stated this is the first incident of S1 regarding inappropriate behavior. ED stated there is no witness for the incident. 6 Out of 6 staff stated they never saw S1 had inappropriate or aggressive behavior. R1 stated this is the first time that S1 had this kind of behavior. 1 out of 5 residents does not remember S1. 3 Out of 5 residents stated they did not see S1 had inappropriate or aggressive behavior. LPA requested R1's physician report, appraisal needs service plan. LPA obtained the facility staff training document regarding resident abuse and reporting requirement. This case needs further investigation. Exit interview was conducted with ED. The report was provided to ED for review and signature. A copy of the report was provided to ED.the state’s words, verbatim · CDSS document, Mar 19, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted a unannounced annual inspection visit, and met with Senior Executive Director (ED) Jennifer Coons. LPA checked 5 staff records (S1 - S5) and 5 resident records (R1 - R5). LPA toured the facility inside and out with ED. LPA toured the main entrance, mail box/snack room, activity room 1 & 2 in Assist Living unit, dining room in Assist Living unit, kitchen, Gym, and courtyard. LPA toured memory care unit activity room 1 & 2, dining room, and patio. The facility has 4 floors. LPA toured the Assist Living unit and Memory care unit apartments and public restrooms. LPA toured inside of apartment rooms 104, 134, 324 and 326. License, personal right posters, food menu, Administrator Certificate, and Specialist diet list were observed posted. 2 medication rooms and medication carts were observed locked. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Knives storage and cleaning product rooms were observed locked. Room temperature was at 74 degree F, and hot water temperature was at 110 degree F in facility. the temperature of refrigerator was at 39 degree F and the temperature of the freezer was at -1 degree F. Fire extinguishers were serviced on 2/26/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. 2 chairs were observed in each stair in the facility. Public restrooms were inspected. LPA tested the bell button system and it works fine. ED stated the last time the facility conducted the emergency and fire drill was on 3/7/2024. No citation was noted for today's inspection. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED.the state’s words, verbatim · CDSS document, Mar 18, 2024

Allegation investigated: A resident had untreated open wound from a fall injury due to neglect/lack of supervision. Facility did not seek timely medical attention for the resident’s wound injury. Facility did not submit an incident report to licensing agency.

Licensing Program Analysts (LPAs) Steve Chang and Mita Partoza conducted an unannounced investigation visit to deliver the investigation findings and met with Director of Resident Care Services (DRCS) Jeeteeh Gigliotti. On 11/30/2023, the Department received allegations that the facility did not seek timely medical attention and neglected care and supervision of a resident herein referred to as R1. On 12/08/2023, the Department conducted an initial investigation visit. LPAs requested resident physician report, appraisal needs and service plan, nurse evaluation report, communication log between the facility and doctor, and doctor order. Continue on LIC9099-C. Page 1 of 3. Substantiated On 11/30/23, the Department received allegations that the facility did not seek timely medical attention and neglected care and supervision for a resident herein referred to as R1. R1 had an untreated wound which was not reported to licensing office. On 12/08/23, the Department conducted an initial investigation and interviewed staff (S1). S1 stated that R1 had an unwitnessed fall sustaining an injury to the left elbow with a superficial skin tear on 11/21/23. S1 stated that R1s fall was reported to responsible party (RP) and medical doctor (MD). S1 stated that R1’s wound was not serious, was cleaned and a band aid was applied. Since it was not serious, the facility did not report R1’s wound to licensing. On 11/27/23, R1’s responsible party moved R1 to another Residential Care Facility for the Elderly (RCFE). It was reported that during R1’s assessment the facility did not inform the prospective facility that R1 sustained a wound on elbow aside from other minor abrasion on his/her knee during an assessment. Based on review of Nurse’s notes dated 11/21/23, it was noted that R1 reported to the Wellness Nurse at 9AM that he/she fell during the night but does not remember how it happened. R1 sustained a left skin tear on left arm and some redness on left knee. R1s wound was cleaned and treated, and dressing applied. R1’s primary care physician (PCP) was notified on the same day [11/21/23] with a reply date of 11/24/23 which states, “can give Tylenol 500mg every 6 hours … and please wash skin tear clean and put band aid over.” On 11/28/2023, R1’s wound was reported to his/her PCP. PCP stated the facility staff did not describe the severity of the wound and how bad it was when he/she received a note from the facility On 11/21/23, the note states that R1 had a skin tear on left arm and some redness on the left knee. PCP prescribed R1 some antibiotics and will require the services of a home Health aide to come and assist with the wound care for R1 at his/her new placement. Based on record review such as R1’s physician’s report dated 5/23/23, R1 has diagnosis of neurocognitive disorder. Continue on LIC9099-C. Page 2 of 3. On 12/05/2023, LPA interviewed R1’s responsible party (referred to as RP). RP stated that on 11/21/23, he/she received a phone call from the facility staff to report that R1 had a fall and PCP was notified who prescribed medication for pain. RP stated there was no mention of R1’s sustaining a wound on the left elbow. RP became aware of R1’s wound on left elbow a day after R1 was admitted at another facility on 11/28/23 reported by the facility nurse, herein referred to as W1. RP stated that R1 moved out from the facility [Belmont Village] on 11/27/23. On 12/08/2023, the Department interviewed staff S1. S1 stated R1 did not complain about pain, per their procedure does not require staff to report to licensing if it is not critical or does not require any hospital visit/emergency. Based on interviews, and records reviewed, of incident submitted to the department, a report was not filed with licensing addressing R1s unusual incident (injury/fall) in November 2023. Based on records review of R1s progress note, no other reports was written after 11/21/2023 that the wound has been addressed. On 12/09/2023 the Department interviewed witness (W1) that R1 was assessed at Belmont Village prior to R1’s placement on 11/27/23. According to W1, it was mentioned by the wellness director or nurse [at Belmont] that R1 had a fall but no mention of an open wound on R1’s left elbow during assessment. W1 stated that R1’s wound discovered when R1’s moved in day on 11/27/23 which was covered by translucent tape over the wound with yellowish color appeared to be infected and wound dressing has not been changed. On 12/10/2023, an interview with W1 was conducted. W1 stated that the facility [Belmont] did not allow them to conduct skin assessment. Based on the Department’s findings, record reviews and interviews, there is sufficient evidence to prove that the allegation of neglect or lack of supervision, not seeking medical attention in a timely manner, and not reporting incident to licensing agency occurred. The preponderance of evidence gathered and analyzed indicated that the allegation is true, therefore, the allegations are substantiated. Deficiencies are cited based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with DRCS Jeeteeh Gigliotti and a copy of the report and appeals rights were provided. Page 3 of 3the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 26-AS-20231130121323

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 24, 2024

87466 Observation of the Resident The see shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.This requirement is not met as evidenced by: Based on records reviewed and interviews, no progress notes that was made to document R1s wound condition after 11/21/2023. This posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Administrator stated to submit a plan of correction by the POC due date to develop a protocol on documentation for residents in care and supervision.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Feb 24, 2024

87465 Incidental Medical and Dental Care. (a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews, and records reviewed, the facility staff did not follow up with R1s PCP after the initial consultation of R1's wound treatment on 11/21/2022. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Administrator stated to submit a plan of correction by POC due date to address wound care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(1)(D) · Plan of correction due date: Mar 1, 2024

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency ...(1) A written report shall be submitted to the licensing agency...(D) Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Based on interviews, and records reviewed, of incident submitted to the department, a report was not filed with licensing addressing R1s unusual incident (injury/fall) in November 2023. This posed an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Administrator stated will submit a plan of correction (POC) on reporting requirements.