Belmont Village Rancho Palos Verdes

Type of visit: Required - 1 Year

On 7/27/2026, Licensing Program Analyst (LPA)Bernadette Allen conducted an unannounced visit to conduct an annual inspection visit. LPA met with Ralph Balbin-Executive Director, and he was informed of the purpose of the visit. The facility is licensed to serve (150) elderly adults aged 60 and above, of which (120) can be non-ambulatory and (30) bedridden. Approved for delayed egress doors and secured perimeters. The facility has an approved hospice waiver for (30). Currently the facility has (123) residents. The facility is a three-story building located within a residential neighborhood. The structure contains a total of 141 resident bedrooms, 27 bedrooms in the neighborhood area and 114 bedrooms in Assisted Living. Each resident bedroom is equipped with its own bathroom. The facility includes a lobby, living room, three lounge areas, a dining room, kitchen, and bistro. A designated Memory Care Unit is located on site. Additional rooms and support areas include housekeeping and janitorial storage closets, three administrative offices, two laundry rooms, an activity room, a separate activity area, a Wellness room, an engineering office, and a beauty salon. The facility also features front and rear patio areas, a gated swimming pool, and multiple outdoor storage sheds. At 11:10 AM, LPA reviewed six (6) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings which appeared to be current. LPA reviewed six (6) residents’ files for admission agreements, updated physician reports, and needs and services plan which appeared to be current. At 2:00 PM, LPA Allen and Ralph Balbin toured the physical plant. There is a pool located on the first floor, gated and locked. LPA inspected a total of (6) bedrooms and (6) bathrooms. The beds and bedding supplies appeared to be in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. LPA Allen observed that the facilities kitchen to have a 5-day supply of perishables and a 7-day supply of non-perishables food items which were stored and maintained properly. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 105.0°F to 120F, and the room temperature ranged from 76°F to 78°F. throughout the facility. The last Fire/Disaster Drills were conducted on 7/23/2026. During the visit, LPA Allen observed that the facility appeared to be clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. An exit interview was conducted, and a copy of the Report was provided to Ralph Balbin /Executive Director.the state’s words, verbatim · CDSS document, Jul 27, 2026

Allegation investigated: Resident was illegally serviced an eviction

On 5/6/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Memory Program Coordinator, Tiffany Alisaje and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 5/6/26 LPA Felisa Shirley reviewed copies of the following records: Staff and Resident Roster, Residence and Services Agreement, Breach of the Resident Services Agreement and the Resident Handbook Notice, 30-Day Notice to Terminate, Identification and Emergency Information, and Physician’s Report. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff - 1 – Staff - 7(S1 – S7), and Resident -1 (R1). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Resident was illegally serviced an eviction It is being reported that R1 was served an eviction notice derived from scenarios that did not occur. Per review on 5/6/26, of the Residence and Services Agreement, R1 has resided at this facility since 12/28/23. On 5/6/26, LPA Shirley observed that R1 acknowledged and signed the Resident Handbook on 12/28/23. On 5/6/26, LPA Shirley observed the, Breach of the Resident services Agreement and the Resident Handbook signed by the Senior Vice President of Regulatory Affairs, dated 11/5/25 stating that R1 has engaged in multiple improper and inappropriate actions in the treatment of staff members at Belmont Village Senior Living. On 5/6/26, LPA Shirley also reviewed the 30 – Day Notice to Terminate, dated 4/21/26 with an effective day on or before 5/21/26. Eviction notice dated 4/21/26 was in compliance and within Title 22 Regulations and was accepted on 4/29/26. LPA interviewed staff 1 – staff 7 (S1 – S7). Of those interviewed 7 out of 7 denied the allegation. LPA interviewed resident 1 (R1), who confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Resident was illegally serviced an eviction,“ therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Memory Care Coordinator, Tiffany Alisaje.the state’s words, verbatim · CDSS document, May 6, 2026 · control 11-AS-20260427094855

Type of visit: Office

On 11/06/2025, at 10:00am, an office meeting was held to discuss Complaint 11-As- 20191203144823. Present at the meeting was Eva Alvarez, Licensing Program Manager (LPA), Wendy Gibbs, Licensing Program Analyst (LPA), Mercedes Kerr, Joel Goldman, Ralph Balbin, and Douglas Armstrong. During the meeting, the LPM reviewed the details of the Complaint. On April 1, 2022, the Department substantiated an allegation of Resident developed multiple pressure wounds while in care. At the time the findings were delivered on April 1, 2022, the Department indicated that an enhanced civil penalty determination was pending, pursuant to Health and Safety Code Section 1569.49(e). The Department is reviewing the complaint for enhanced civil penalty for serious bodily injury pursuant to H&S 1569.49(e). The total amount for the civil penalty totals $10,000 for Serious Bodily Injury. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 6, 2025

Allegation investigated: Staff did not abide to the admission agreement.

On 10/27/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to deliver amended report for the allegation mentioned above. LPA met with Ralph Balvin, Administrator, and the purpose of the visit was explained. LPA was granted entrance to the facility. **This report supersedes the report created and delivered on 08/22/25. This report is to clarify findings. On 08/22/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted a subsequent unannounced complaint visit to further investigate the above-mentioned allegation and deliver findings. LPA met with Nina Khatchatrian, Director of Resident Care, and the purpose of the visit was explained. LPA was granted access to the facility. Ralph Balbin, Administrator, later joined LPA Gonzalez for the visit. Continued on LIC9099-C Unsubstantiated The investigation consisted of the following: On 06/11/25, LPA Gonzalez requested and reviewed the following documents: staff roster, resident roster, Face Sheet, Physician's Report, Residence and Services Agreement, Amendment to Residence and Service Agreement for Change in Residence, Rent Increase notices dated: 01/10/20, 01/27/21, 01/15/22, 01/30/23, and 01/30/24, service rate notices dated: 08/07/21, 10/28/22, 10/30/23, and letters of conservatorship for resident #1 (R1). Additionally, LPA conducted interviews with staff #1-#2 (S1-S2) and attempted to interview witness #1 (W1). On 08/22/25, LPA Gonzalez received the following documents: Rent Increase letters dated: 01/10/20, 01/27/21, 01/15/22, 01/30/23, 01/30/24, and 01/28/25, Support Fee Increase letters dated: 08/27/21, 08/28/22, 10/30/23, 10/25/24, and Residence and Service Agreement. Additionally, LPA conducted interviews with staff #3 (S3), W1, residents #2-#9 (R2-R9), and attempted to interview R1. The investigation revealed the following: Allegation: Staff did not abide to the admission agreement. It is being alleged that a resident and/or representative never received a 60-day notice for enhanced personal care charges. It is also being alleged that the resident and/or representative never received a 60-day notice for rent increases. On 06/11/25 LPA conducted interviews with S1-S2, and on 08/22/25, LPA conducted an interview with S3. Of those interviewed, 3 out of 3 staff denied the allegation. 3 out of 3 staff stated that residents and/or representative are notified 60 days in advance regarding rent increases. 3 out 3 staff stated that residents and/or representative are notified in advance regarding any service charge increase. On 08/22/25, LPA conducted interviews with R2-R9. LPA attempted to interview R1 but was unable to due to R1’s diagnosis. Of those interviewed, 8 out of 8 residents could not corroborate with the allegation. 5 out of 8 residents stated that staff went over the Admission Agreement with their representative and a copy was provided prior to moving in, and 1 out of 8 residents stated that staff went over the Admission Agreement with them and a copy was provided prior to moving in, and 2 out of 8 residents said they did not know if staff went over the Admission Agreement with them or their representative and if a copy was provided prior to moving in. 3 out of 8 residents stated that the facility notifies their representative in advance regarding any rent increases, and service charge increases, 1 out of 8 residents stated that the facility notifies them in advance regarding any rent increases, and service charge increases, and 4 out of 8 residents said they did not know if the facility notifies them in advance regarding any rent increases, and service charge increases. Continued on LIC9099-C 8 out of 8 residents stated that they are receiving the services they are being charged for. 8 out of 8 residents stated that they are satisfied with the services being provided to them. On 08/22/25, LPA conducted an interview with W1, and they indicated that the facility provides them with rent increase letters, and support fee increase letters in a timely manner, and at least 60-days in advance. On 08/22/25, LPA Gonzalez conducted a review of records. LPA reviewed the Residence and Service Agreement dated 03/01/15, and it states that the facility may change any other fee described within the agreement upon sixty (60) days prior written notice to the resident and/or representative at any time during the term of the agreement. In the event of a rate increase, the facility will include with the notice of the increase the reasons for the increase and a general description of the additional costs that the facility has incurred. LPA reviewed Rent Increase letters dated: 01/10/20, 01/27/21, 01/15/22, 01/30/23, 01/30/24, and 01/28/25 and observed that all letters were mailed to R1’s current and past representatives at least 60 days prior to when the rent increase took effect. LPA reviewed Support Fee Increase letters dated: 08/27/21, 08/28/22, 10/30/23, 10/25/24 and observed that all letters were mailed to R1’s current and past representatives at least 60 days prior to when the support fee increase took effect. Based on record review, and interviews conducted, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of this report was provided to Ralph Balbin, Administrator.the state’s words, verbatim · CDSS document, Oct 27, 2025 · control 11-AS-20250606113252

Allegation investigated: Resident sustained a fracture while in care.

On 10/09/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Belmont Village Rancho Palos Verdes and was greeted by Administrator Ralph Balbin (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S5, resident R1-R12, witness (W1). LPA Calderon obtained the following records: Admission Agreement (dated 06/04/2014). Email from resident family members (dated 10/01/2025), Incident report (dated 08/25/2025), Preplacement Appraisal (dated 05/05/2014), Physician order (dated 10/05/2025), Resident Assessment Plan (dated 07/01/2025), Physician Report (dated 07/22/2024) for R1. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Resident sustained a fracture while in care. This complaint alleged that the facility staff dropped R1 and caused fractures to leg. LPA Calderon noted staff giving morning medications to residents. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions. Reviewed incident report (dated 08/25/2025), report indicates that R1 complained of pain. The report does not suggest that R1 was dropped by staff or had a fall. The preplacement appraisal (dated 05/05/2014) noted R1 has osteoporosis and vitamin D deficiency. Physician Orders (dated 10/05/2025) noted vitamin D3. Reviewed the discharge paperwork for R1. Torrance Memorial Hospital records indicate that R1 has cognitive issues and no mention of osteoporosis. The Physician Report (dated 07/22/2024) indicates that R1 has osteoporosis. The residential care plan (dated 07/15/2025) indicates osteoporosis with vitamin D needed. 5 out of 5 staff deny the allegation. R1 cannot be interviewed due to cognitive issues. 11 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “resident sustained fracture while in care” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Ralph Balbin (S1).the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 11-AS-20250826170519

Allegation investigated: Staff charged resident for services not rendered

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on the report created 5/12/25. On 5/12/25 at 8:50 am, Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Executive Director, Ralph Balbin and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 4/24/25 LPA requested and reviewed copies of the following records: Staff Roster, Resident Roster, Admission Agreement, Physician’s report, Assessments, Service Plan, Statement of Account, Supplemental Support Services, Schedules of bathing, housekeeping and laundry. LPA Felisa Shirley toured the facility and interviewed Staff #1 – 10 and Residents #2 – 10. R1 was not available due to diagnosis. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff charged resident for services not rendered On 5/12/25, LPA Felisa Shirley reviewed copies of R-1’s Residence and Services Agreement, signed 5/30/14. Per review of the agreement, “You may terminate this agreement at any time, with or without cause, effective at the end of the Initial Term (as defined in Section III.A) or thereafter by giving the Community Manager or his/her designee thirty (30) days’ written notice of termination, which shall provide a forwarding address. You need not cite a specific reason for the termination. Termination shall be effective as of midnight on the thirtieth (30th) day after receipt of written notice of termination. LPA Felisa reviewed R-1’s Resident Assessment and Service Plan dated, 12/12/24. This assessment outlines R-1’s residential care and services provided. During file review, LPA Shirley observed the Supplemental Support Services which provided prices for 2024 for Circle of Friends Enhanced Personal Care II. LPA Shirley reviewed R-1’s Statement of Account and observed that R-1 owes a balance of unpaid rent and unpaid Circle of Friends Enhanced Personal Care II for the month of January 2025 as R1 did not provide a 30-day written notice of termination. LPA Shirley interviewed staff-1 thru staff-10 (S-1 thru S-10). LPA asked, does staff charge residents for services not rendered. Of those interviewed, 6 out of 10 staff answered yes, and 4 staff did not know. LPA interviewed Resident-2 thru Resident-10 (R-2 thru R-10). LPA asked, have you ever been charged for services not provided for you. Of those interviewed, 6 out of 9 answered no, 1 answered yes and 1 resident did not answer. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Executive Director, Ralph Balbin.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 11-AS-20250414155636

Allegation investigated: Staff did not provide resident with laundry service Staff did not provide resident with housekeeping service Staff did not assist resident with showering Staff did not ensure facility was maintained sanitary

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on the report created 4/24/25. On 4/24/25 at 8:50 am, Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Executive Director, Ralph Balbin and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 4/24/25 LPA requested and reviewed copies of the following records: Staff Roster, Resident Roster, Admission Agreement, Physician’s report, Assessments, Service Plan, Schedules of bathing, housekeeping and laundry. LPA Felisa Shirley toured the facility and interviewed Staff #1 – 10 and Residents #2 – 10. R1 was not available due to diagnosis. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not provide resident with laundry service. The details of the complaint allege that staff improperly stored soiled garments within the resident’s closet. LPA Shirley reviewed PAL Approach Chart and Service Plan for R1, July 2024 through December 2024. During review, LPA Shirley observed that R1’s laundry day was Fridays. LPA Shirley observed the initials of the caregivers providing the laundry service for the week and that laundry service was consistent. LPA Shirley did not observe soiled garments in the closet as R1 transferred out of this facility on 12/27/25. LPA Shirley interviewed staff-1 thru staff-10 (S-1 thru S-10). LPA asked, how often does staff wash the resident’s clothes. Of those interviewed, 10 out of 10 staff answered twice a week. LPA interviewed Resident-2 thru Resident-10 (R-2 thru R-10). LPA asked, how often does staff clean your clothes. Of those interviewed, 7 out of 9 answered once a week, and 2 had other answers. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not provide resident with housekeeping services The details of the complaint allege that R1’s room was unclean. Per review of the Admissions Agreement signed 5/30/14, Belmont Village will provide weekly housekeeping services for the Con'd on 9099-C the residents. LPA Shirley reviewed PAL Approach Chart and Service Plan for R1, July 2024 through December 2024. During review, LPA Shirley observed that R1’s housekeeping day was Fridays. During review, LPA Shirley observed that there were specific areas of R1’s room that were tidied up daily. Per the Executive Director’s interview, the rooms are deep cleaned weekly. Per review of the PAl Approach Chart and Service Plan, LPA Shirley observed the initials of the staff members providing housekeeping services consistently. LPA Shirley did not observe an unkept room as R1 transferred out of this facility on 12/27/25. LPA Shirley interviewed staff-1 thru staff-10 (S-1 thru S-10). LPA asked, how often does the housekeeping staff clean the resident’s rooms. Of those interviewed, 9 out of 10 staff answered once a week, one answered 2 or 3 times a week. LPA interviewed Resident-2 thru Resident-10 (R-2 thru R-10). LPA asked, how often does staff clean your room. Of those interviewed, 3 out of 9 answered once a week, and 6 had other answers. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not assist resident with showering The details of the complaint allege that facility staff stopped giving R1 showers. LPA reviewed R1’s Physicians Report signed, 10/24/23 and observed that R1 was not able to bathe herself. LPA reviewed R1’s assessment dated, 12/12/24. The assessment stated that R1 needed hands Con'd on 9099-C on assistance with showers. LPA Shirley reviewed the PAL Approach Chart and Service Plan for R1, July 2024 through December 2024. During review, LPA Shirley observed that R1’s assigned shower days were Mondays, Wednesdays and Fridays. Upon further review of the PAL Approach Chart and Service Plan, LPA Shirley observed the initials of the caregivers assisting R1 with her showers and that this service continued until the day R1 moved out 12/27/25. LPA Shirley interviewed staff-1 thru staff-10 (S-1 thru S-10). LPA asked, does staff assist residents with their showering needs. Of those interviewed, 10 out of 10 staff answered yes. LPA interviewed Resident-2 thru Resident-10 (R-2 thru R-10). LPA asked, does staff assist you with your showering needs. Of those interviewed, 8 out of 9 answered that they are independent, and 1 resident did not answer. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not ensure facility was maintained sanitary The details of the complaint allege that Belmont Village failed to fulfill the terms of their care agreement as the carpet in R1’s room #205 was unclean. LPA Shirley toured the facility to observe the carpeting in room #205 and observed that the room had been upgraded for the next resident. There was no longer carpet in the room. Room #205 now has vinyl wood flooring. LPA reviewed pictures provided and observed that there was a rug covering a soiled area near where the bed used to be situated. This area was not observed until the resident transferred out 12/27/25. Con'd on 9099-C LPA Shirley interviewed staff-1 thru staff-10 (S-1 thru S-10). LPA asked, does staff maintain a sanitary facility. Of those interviewed, 10 out of 10 staff answered yes. LPA interviewed Resident-2 thru Resident-10 (R-2 thru R-10). LPA asked, does staff maintain a sanitary facility. Of those interviewed, 8 out of 9 answered yes, and 1 resident did not answer. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Regarding the allegations, the Department found no evidence to support the allegations mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegations are Unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Executive Director, Ralph Balbin.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 11-AS-20250414155636

Allegation investigated: Staff did not abide to the admission agreement.

On 08/22/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted a subsequent unannounced complaint visit to further investigate the above-mentioned allegation and deliver findings. LPA met with Nina Khatchatrian, Director of Resident Care, and the purpose of the visit was explained. LPA was granted access to the facility. Ralph Balvin, Administrator, later joined LPA Gonzalez for the visit. The investigation consisted of the following: On 06/11/25, LPA Gonzalez requested and reviewed the following documents: staff roster, resident roster, Face Sheet, Physician's Report, Residence and Services Agreement, Amendment to Residence and Service Agreement for Change in Residence, Rent Increase notices dated: 01/10/20, 01/27/21, 01/15/22, 01/30/23, and 01/30/24, service rate notices dated: 08/07/21, 10/28/22, 10/30/23, and letters of conservatorship for resident #1 (R1). Additionally, LPA conducted interviews with staff #1-#2 (S1-S2) and attempted to interview witness #1 (W1). Unsubstantiated On 08/22/25, LPA Gonzalez received the following documents: Rent Increase letters dated: 01/10/20, 01/27/21, 01/15/22, 01/30/23, 01/30/24, and 01/28/25, Support Fee Increase letters dated: 08/27/21, 08/28/22, 10/30/23, 10/25/24, and Residence and Service Agreement. Additionally, LPA conducted interviews with staff #3 (S3), W1, residents #2-#9 (R2-R9), and attempted to interview R1. The investigation revealed the following: Allegation: Staff did not abide to the admission agreement. It is being alleged that a resident and/or representative never received a 60-day notice for enhanced personal care charges. It is also being alleged that the resident and/or representative never received a 60-day notice for rent increases. On 06/11/25 LPA conducted interviews with S1-S2, and on 08/22/25, LPA conducted an interview with S3. Of those interviewed, 3 out of 3 staff denied the allegation. 3 out of 3 staff stated that residents and/or representative are notified 60 days in advance regarding rent increases. 3 out 3 staff stated that residents and/or representative are notified in advance regarding any service charge increase. On 08/22/25, LPA conducted interviews with R2-R10. LPA attempted to interview R1 but was unable to due to R1’s diagnosis. Of those interviewed, 8 out of 9 residents could not corroborate with the allegation. 7 out of 9 residents stated that staff went over the Admission Agreement with their representative and a copy was provided prior to moving in. 1 out of 9 residents stated that staff went over the Admission Agreement and a copy was provided prior to moving in. 7 out of 9 residents stated that the facility notifies their representative in advance regarding any rent increases, and service charge increases. 1 out of 9 residents stated that the facility notifies them in advance regarding any rent increases, and service charge increases. 8 out of 9 residents stated that they are receiving the services they are being charged for. 8 out of 9 residents stated that they are satisfied with the services being provided to them. On 08/22/25, LPA conducted an interview with W1, and they indicated that the facility provides them with rent increase letters, and support fee increase letters in a timely manner, and at least 60-days in advance. Continued on LIC9099-C On 08/22/25, LPA Gonzalez conducted a review of records. LPA reviewed the Residence and Service Agreement dated 03/01/15, and it states that the facility may change any other fee described within the agreement upon sixty (60) days prior written notice to the resident and/or representative at any time during the term of the agreement. In the event of a rate increase, the facility will include with the notice of the increase the reasons for the increase and a general description of the additional costs that the facility has incurred. LPA reviewed Rent Increase letters dated: 01/10/20, 01/27/21, 01/15/22, 01/30/23, 01/30/24, and 01/28/25 and observed that all letters were mailed to R1’s current and past representatives at least 60 days prior to when the rent increase took effect. LPA reviewed Support Fee Increase letters dated: 08/27/21, 08/28/22, 10/30/23, 10/25/24 and observed that all letters were mailed to R1’s current and past representatives at least 60 days prior to when the support fee increase took effect. Based on record review, and interviews conducted, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is unsubstantiated. No deficiencies were cited during this investigation. An exit interview was conducted, and a copy of this report was provided to Ralph Balvin, Administrator.the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 11-AS-20250606113252

Type of visit: Required - 1 Year

On 6/04/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Ralph Balbin/Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (150) elderly adults ages 60 and above, of which (120) can be non-ambulatory and (30) bedridden. Approved for delayed egress doors and secured perimeters. The facility has an approved hospice waiver for (20). Currently the facility has (127) residents. The facility is a three-story structure located in a residential neighborhood. It consists of the following: (27) resident bedrooms in the neighborhood and (114) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, a lobby, a living room, (3) lounge areas, a dining room, a kitchen, a bistro, a Memory Care Unit. housekeeping/janitorial storage closets, (3) administrative offices, (2) laundry rooms, an activity room, a Wellness room, an engineering office, a beauty salon, an activity area, front and rear patio area, a gated pool, and outdoor storage sheds. LPA Iniguez and the Executive Director toured the physical plant. There is a pool located on the first floor, gated and locked. LPA inspected a total of (8) bedrooms and (8) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. The bathrooms were found to be in compliance with Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 115.5°F to 117.2°F, and the room temperature ranged from 76°F to 78°F. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care in the dementia unit. The kitchen was inspected, and sufficient perishable and non-perishable food was available, which was maintained properly. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on May 21, 2025. A review of (6) residents' service files and (6) staff personnel files was maintained in order. LPA reviewed (6) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA. Facility Annual Fess current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Ralph Balbin /Executive Director.the state’s words, verbatim · CDSS document, Jun 4, 2025

Allegation investigated: Staff charged resident for services not rendered

On 5/12/25 at 8:50 am, Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Executive Director, Ralph Balbin and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 4/24/25 LPA requested and reviewed copies of the following records: Staff Roster, Resident Roster, Admission Agreement, Physician’s report, Assessments, Service Plan, Statement of Account, Supplemental Support Services, Schedules of bathing, housekeeping and laundry. LPA Felisa Shirley toured the facility and interviewed Staff #1 – 10 and Residents #2 – 10. R1 was not available due to diagnosis. Con'd on 9099-C Unsubstantiated The investigation revealed the following: On 5/12/25, LPA Felisa Shirley reviewed copies of R-1’s Admission Agreement, signed 5/30/14. LPA Felisa reviewed R-1’s Resident Assessment and Service Plan dated, 12/12/24. During file review, LPA Shirley observed the Supplemental Support Services which provided prices for 2024 for Circle of Friends Enhanced Personal Care II. LPA Shirley reviewed R-1’s Statement of Account and determined that R-1 owes a balance of unpaid rent for January 2025 as R1 did not provide a 30 day notice to move. LPA Shirley interviewed staff-1 thru staff-10 (S-1 thru S-10). LPA asked, does staff charge residents for services not rendered. Of those interviewed, 6 out of 10 staff answered yes, and 4 staff did not know. LPA interviewed Resident-2 thru Resident-10 (R-2 thru R-10). LPA asked, have you ever been charged for services not provided for you. Of those interviewed, 6 out of 9 answered no, 1 answered yes and 1 resident did not answer. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Regarding the allegation, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Con'd on 9099-C No deficiencies were cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Executive Director, Ralph Balbin.the state’s words, verbatim · CDSS document, May 12, 2025 · control 11-AS-20250414155636

Allegation investigated: Staff did not provide resident with laundry service Staff did not provide resident with housekeeping service Staff did not assist resident with showering Staff did not ensure facility was maintained sanitary

On 4/24/25 at 8:50 am, Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Executive Director, Ralph Balbin and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 4/24/25 LPA requested and reviewed copies of the following records: Staff Roster, Resident Roster, Admission Agreement, Physician’s report, Assessments, Service Plan, Schedules of bathing, housekeeping and laundry. LPA Felisa Shirley toured the facility and interviewed Staff #1 – 10 and Residents #2 – 10. R1 was not available due to diagnosis. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not provide resident with laundry service. The details of the complaint allege that staff improperly stored soiled garments within the resident’s closet. LPA Shirley reviewed PAL Approach Chart and Service Plan for R1, July 2024 through December 2024. During review, LPA Shirley observed that R1’s laundry day was Fridays. LPA Shirley observed the initials of the caregivers providing the laundry service for the week and that laundry service was consistent. LPA Shirley did not observe soiled garments in the closet as R1 transferred out of this facility on 12/27/25. LPA Shirley interviewed staff-1 thru staff-10 (S-1 thru S-10). LPA asked, how often does staff wash the resident’s clothes. Of those interviewed, 10 out of 10 staff answered twice a week. LPA interviewed Resident-2 thru Resident-10 (R-2 thru R-10). LPA asked, how often does staff clean your clothes. Of those interviewed, 7 out of 9 answered once a week, and 2 had other answers. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not provide resident with housekeeping services The details of the complaint allege that R1’s room was unclean. Per review of the Admissions Agreement signed 5/30/14, Belmont Village will provide weekly housekeeping services for the Con'd on 9099-C the residents. LPA Shirley reviewed PAL Approach Chart and Service Plan for R1, July 2024 through December 2024. During review, LPA Shirley observed that R1’s housekeeping day was Fridays. During review, LPA Shirley observed that there were specific areas of R1’s room that were tidied up daily. Per the Executive Director’s interview, the rooms are deep cleaned weekly. LPA Shirley observed the initials of the staff members providing housekeeping services consistently. LPA Shirley did not observe an unkept room as R1 transferred out of this facility on 12/27/25. LPA Shirley interviewed staff-1 thru staff-10 (S-1 thru S-10). LPA asked, how often does the housekeeping staff clean the resident’s rooms. Of those interviewed, 9 out of 10 staff answered once a week, one answered 2 or 3 times a week. LPA interviewed Resident-2 thru Resident-10 (R-2 thru R-10). LPA asked, how often does staff clean your room. Of those interviewed, 3 out of 9 answered once a week, and 6 had other answers. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not assist resident with showering The details of the complaint allege that facility staff stopped giving R1 showers. LPA reviewed R1’s Physicians Report signed, 10/24/23 and observed that R1 was not able to bathe herself. LPA reviewed R1’s assessment dated, 12/12/24. The assessment stated that R1 needed hands Con'd on assistance with showers. LPA Shirley reviewed PAL Approach Chart and Service Plan for R1, July 2024 through December 2024. During review, LPA Shirley observed that R1’s assigned shower days were Mondays, Wednesdays and Fridays. LPA Shirley observed the initials of the caregivers assisting R1 with her showers and that this service continued until the day R1 moved out 12/27/25. LPA Shirley interviewed staff-1 thru staff-10 (S-1 thru S-10). LPA asked, does staff assist residents with their showering needs. Of those interviewed, 10 out of 10 staff answered yes. LPA interviewed Resident-2 thru Resident-10 (R-2 thru R-10). LPA asked, does staff assist you with your showering needs. Of those interviewed, 8 out of 9 answered that their independent, and 1 resident did not answer. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not ensure facility was maintained sanitary The details of the complaint allege that Belmont Village failed to fulfill the terms of their care agreement as the carpet in R1’s room #205 was unclean. LPA Shirley toured the facility to observe the carpeting in room #205 and observed that the room had been upgraded for the next resident. There was no longer carpet in the room. Room #205 now has vinyl wood flooring. LPA reviewed pictures provided and observed that there was a rug covering a soiled area near where the bed used to be situated. This area was not observed until the resident transferred out 12/27/25. Con'd on 9099-C LPA Shirley interviewed staff-1 thru staff-10 (S-1 thru S-10). LPA asked, does staff maintain a sanitary facility. Of those interviewed, 10 out of 10 staff answered yes. LPA interviewed Resident-2 thru Resident-10 (R-2 thru R-10). LPA asked, does staff maintain a sanitary facility. Of those interviewed, 8 out of 9 answered yes, and 1 resident did not answer. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Regarding the allegations, the Department found no evidence to support the allegations mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegations are Unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Executive Director, Ralph Balbin.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 11-AS-20250414155636

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Lack of supervision resulting in resident wandering away from the facility. Staff not administering resident’s medication as prescribed. Staff did not provide medical attention to resident. Staff confiscated resident’s belongs.

On 12/09/24 The Department of Social Services, Community Care Licensing Division (CCLD) staff conducted a subsequent, unannounced, complaint visit at the facility. CCLD was met by staff one, Ralph Balbin Executive Director (S1), and the purpose of the visit was explained. The investigation consisted of the following: On 12/09/24 CCLD staff interviewed four (4) residents out of one-hundred and thirty (130), and two (2) staff, out of one-hundred and fifty-four (154). CCLD requested additional facility documents, including the personnel report and training records of four (4) staff and communications between the two (2) parties in question. On 08/09/24 LPA requested facility documents, which include the medication admission record (MAR) of three (3) residents. LPA interviewed five (5) residents and four (4) staff. Report continues, see LIC-9099C Unsubstantiated The investigation revealed the following: Regarding the allegation: “Lack of supervision resulting in resident wandering away from the facility.”, it has been alleged that a staff member brought a resident down to the ground floor and left the resident unobserved which resulted in a resident leaving the facility. Record reviews show that one resident (R1) had left from the facility on 11/26/24. The facility had notified CCLD of the incident of R1's departure. In the details of the nurse's notes, R1 had departed the facility with their private caregiver (PC) and two (2) additional staff from the facility. Staff were aware of R1's departure and followed the resident (R1) and PC. This resident (R1) was located and were transported back to the facility, without any changes of conditions noted. Interviews have revealed that all nine (9) residents and all six (6) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff not administering resident’s medication as prescribed.”, it has been alleged a resident was not administered half of their medication for 5 days. Record reviews have revealed that R1 was in transition between the initial lease agreement, which was conducted on 09/29/23, and R1's actual date of admission on 11/22/23. The facility was not in possession of the medications in question, yet placed an order for the medications in question on 11/22/23. Interviews revealed that all nine (9) residents and all six (6) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff did not provide medical attention to resident.”, it has been alleged that staff members did not provide medical attention to resident’s chronic condition which led to an infection. Record reviews have indicated that the community nurse, staff two (S2), had arrived to R1's room after the report of R1's cough, received on 07/30/24. R1's PC then informed S2 that the "as-needed" medication had already been provided. According to the facilities' medication management plan, "Residents receiving medication management services at the community, other than dementia Neighborhood residents, are expected to receive their medication at the wellness center or other designated area." which is against the facilities standard of practice. Interviews have revealed that all nine (9) residents and all six (6) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Report continues, see LIC-9099C. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff confiscated residents’ belongings.”, it has been alleged that during a resident’s visit to the Dr.’s office, staff had taken all the over-the-counter, "as needed", medication from R1's room. Record reviews revealed the following: R1 was admitted under "Circle of friends" which is a program targeted towards residents with cognitive decline, with programs specifically tailored to support a variety of residents in care. According to the admissions agreement, "Residents receiving medication management services at the community, other than dementia Neighborhood residents, are expected to receive their medication at the wellness center or other designated area.". Upon discovering that the medication had already been administered by the PC, S2 held the medication to prevent a potential overdose. S1 further stated, "upon discovering the fact that medication(s) were being stored in R1's room, facility staff conducted a medication audit in R1's room which resulted in the discovery of multiple medicines being stored outside of the facilities' medication practice. This, in turn, resulted in the medication being confiscated and was later provided to R1's family member." Interviews have revealed that all nine (9) residents and all six (6) staff have denied the allegation has taken place, with Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. An exit interview was held with Ralph Balbin, Executive Director (S1), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Dec 9, 2024 · control 11-AS-20240807143729

Type of visit: Required - 1 Year

On 6/7/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Ralph Balbin /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (150) elderly adults ages 60 and above, of which (120) can be non-ambulatory and (30) may be bedridden. The facility has an approved hospice waiver for (20). Approved for delayed egress. The facility is a three-story structure located in a residential neighborhood. It consists of the following: (27) resident bedrooms in the neighborhood and (114) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, a lobby, a living room, (3) lounge areas, a dining room, a kitchen, a bistro, a Memory Care Unit. housekeeping/janitorial storage closets, (3) administrative offices, (2) laundry rooms, an activity room, a Wellness room, an engineering office, a beauty salon, an activity area, front and rear patio area, a gated pool, and outdoor storage sheds. LPA Iniguez and the Executive Director toured the physical plant. There is gated pool on the premises, and no obstructions were observed. LPA inspected a total of (9) bedrooms and (9) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113.5°F to 118.2°F, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills was conducted on 5/16/24. A review of (8) residents' service files and (6) staff personnel files was maintained in order. LPA reviewed (8) Medication Administration Records (MARs) no discrepancies were found. Delayed egress checked. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -Can of pesticide found on facility’s kitchen food pantry. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Ralph Balbin / Executive Director.the state’s words, verbatim · CDSS document, Jun 7, 2024

Allegation investigated: Staff do not meet resident's incontinence needs. Staff do not meet resident's dietary needs. Staff do not follow resident's physician's order. Staff did not provide resident with clean linen. Staff punished resident for behavior. Staff did not provide resident with housekeeping. Staff do not ensure that resident is hydrated.

On 04/17/24, at 09:30am, Licensing Program Analyst (LPA) Perry Scott conducted a subsequent unannounced visit to the facility and was greeted by Ralph Balbin, Executive Director. LPA explained the purpose of this visit is to gather additional information and deliver findings for the allegations mentioned above. The investigation consisted of the following: An initial complaint visit was completed by LPA Jeremiah Randle on 01/03/23. A subsequent visit was completed by LPA Perry Scott on 04/17/24. LPA investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R10). Resident/Staff Roster, Admission Agreement, Needs and Service Plan, ID/Emergency information, Physicians Report, Doctor’s notes, Preplacement Appraisal information, Daily Assessment & Turning and Repositioning logs were obtained from the facility. The investigation revealed the following: Allegation #1- Staff do not meet resident's incontinence needs. Report continued on LIC9099-C Unsubstantiated The details of the complaint alleged that the facility on 12/29/2022, left R1 in a soiled diaper because the facility is understaffed resulting in R1’s needs not being met. On 04/17/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff do not meet resident's incontinence needs. All staff (S1-S5) stated that all residents who are incontinent have personal care checks every two hours or more depending on the resident and their care plan. The staff also noted that R1 had a Personal Assistance Liaison assigned to R1 because R1 needed more one on one assistance. LPA examined the facilities PAL Approach Chart and Services log for R1 and observed that R1’s incontinence needs were being met and charted by staff with the date and times R1 needed assistance. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not meet resident's incontinence needs. Residents stated that they did not have any problems with the staff assisting them with their personal care needs; and that they were satisfied with their care and supervision at the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not meet resident's incontinence needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 2- Staff do not meet resident's dietary needs. The details of the complaint alleged that the facility did not serve R1 breakfast or lunch on two occasions because the staff did not have the time to do so. On 04/17/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff do not meet resident's dietary needs. All staff (S1-S5) stated that R1 was served meals three times per day in addition to snacks, water, and other fluids throughout the day. The resident was never denied meals, according to staff. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not meet resident's dietary needs. Residents stated that they were happy with the care and supervision being provided to them, and that their dietary needs are being met. They also stated that they get more than enough food and fluids throughout the day from staff. Based on interviews, there is insufficient evidence to support the allegation that Staff do not meet resident's dietary needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report continued on LIC 9099-C Allegation # 3- Staff do not follow resident's physician's order. The details of the complaint alleged that the facility did not follow the resident’s physicians order because R1 had a stage 2 pressure ulcer to the coccyx area. On 04/17/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff do not follow resident's physician's order. All staff (S1-S5) stated that R1’s physicians order was followed by staff and that R1 had a Home Health Nurse that would come and take care of R1’s wound weekly. Staff stated that R1 was repositioned and assisted with ADL’s daily by staff when not assisted by R1’s Personal Assistance Liaison or the Home Health Nurse. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not follow resident's physician's order. Residents stated that any orders given by their primary care physician is followed by the staff and have not had any issues in this area. Based on interviews and records reviewed there is insufficient evidence to support the allegation that Staff do not follow resident's physician's order. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 4- Staff did not provide resident with clean linen. The details of the complaint alleged that the facility did not provide the resident with clean linens. It is reported that R1’s bed was made although the sheet had a large urine stain on it. On 04/17/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff did not provide resident with clean linen. All staff (S1-S5) state that linens are washed and cleaned weekly for all residents. But staff also stated that if a resident has an accident and soiled the sheets, they are cleaned upon occurrence, and the bed is made afterwards with clean sheets. LPA interviewed R1-R10 about the allegation and 9 of 10 resident’s that were interviewed denied the allegation that Staff did not provide resident with clean linen. Residents stated that the facility cleans their linen weekly but if they were to have an accident and soil the sheets, they would be cleaned immediately. Based on interviews there is insufficient evidence to support the allegation that Staff did not provide resident with clean linen. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report continued on LIC 9099-C Allegation # 5- Staff punished resident for behavior. The details of the complaint alleged that the resident has behavior problems, and that staff punishes resident by placing resident in the memory care unit leaving resident to scream. On 04/17/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff punished resident for behavior. All staff (S1-S5) stated that the facility does not punish or discipline its residents because of behavior issues. They state that all residents are treated with dignity and respect and that those residents that have behavior issues are redirected with behavior modification and allowed to express themselves and given time to relax. Once they are relaxed, they are redirected to get involved with activities and other stimuli to control their outbursts. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff punished resident for behavior. Residents stated that the staff has never punished or disciplined them in any way. Moreover, they state that they have never heard the staff raise their voices at anyone while they have been living here. Based on interviews, there is insufficient evidence to support the allegation that Staff punished resident for behavior. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation # 6- Staff did not provide resident with housekeeping. The details of the complaint alleged that the facility failed to clean the resident’s room because there was food on the floor, and it was not known how long it had been there. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff did not provide resident with housekeeping. All staff (S1-S5) state that the residents’ rooms are given a thorough cleaning weekly. However, housekeeping checks the rooms daily to empty the trash or vacuum if needed. All deny that the facility is not providing the resident with housekeeping. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff did not provide resident with housekeeping. Residents stated that housekeeping comes daily and that they deep clean the rooms once per week. They further state that anytime they have an issue, the facility always resolves it in a timely manner. Based on interviews, there is insufficient evidence to support the allegation that Staff did not provide resident with housekeeping. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report continued on LIC 9099-C Allegation # 7- Staff do not ensure that resident is hydrated. The details of the complaint alleges that the facility does not ensure the resident is properly hydrated. On 04/17/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff do not ensure that resident is hydrated. All staff (S1-S5) stated that all residents are given fluids throughout the day and with each meal served. They further state that the facility has several water stations through the facility, a bistro that serves food and different beverages, and that water is provided to the residents in their room via a refrigerator. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff did not assist resident with bathing. Residents stated that the staff does assist them with grooming and bathing. The residents further stated that are happy with the care and supervision provided by the staff. Based on interviews there is insufficient evidence to support the allegation that Staff do not ensure that resident is hydrated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with Ralph Balbin, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 17, 2024 · control 11-AS-20221229141832

Allegation investigated: Facility staff are not taking measures to prevent the spread of contagious diseases.

On 1/5/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Ralph Balbin /Executive Director. LPA explained the purpose of this visit. Investigation Consisted of the Following: Administrator’s Interview (A#1), Resident interviews (R#1-R#11), Staff interviews (S#1-S#11), a complete tour of the facility. LPA obtained and reviewed the following documents: Resident’s Roster, Personnel Roster, Copy of the LIC 9282-Residential Infection Control Plan, Copy of LIC 610E-Emergency and Disaster Plan for Residential Care Facilities for the Elderly, Copy of COVID-19 Overview and Infection Prevention and Control Priorities in non-U. S Healthcare Settings, Copies of Staff In-Services from January-November 2023 and sign in sheets. Evaluation Report continues LIC 9099-C Unsubstantiated Allegation: Facility staff are not taking measures to prevent the spread of contagious diseases. The details of the complaint alleged that facility staff are not taking measures to prevent the spread of contagious diseases. During the records review, LPA observed the Facility’s Residential infection control plan and the Emergency and disaster plan for residential care facilities for the elderly; both plans are current and updated. Also, LPA observed guidelines regarding how to prevent infection by COVID-19. In addition, LPA reviewed the In-services done by the facility to the staff from January to November 2023. LPA observed in the in-service topics such as Universal precautions for infection control, COVID-19 plan, COVID-19 testing sites and kits, Use of PPE (Personal Protective Equipment) when handling COVID-19-positive residents, and Bloodborne pathogens and PPE. During a physical tour of the facility, LPA observed sanitation stations distributed in the common areas and signs regarding washing hands at all times. During an interview with the Administrator (A#1), he stated that as of today, there is no outbreak at the facility, and when it comes to following proper infection precautions, LPA asked the Executive Director what the protocol is. He responded ‘’When we have an infection precaution happening with the residents. First, we isolate the possible positive resident; we do contact tracing to see how many people the resident has been in contact with, and then we disinfect common areas and surface areas. For the resident in isolation in their apartment, we used PPE and have a station outside their room for the staff. When we have a positive case, we serve food in their apartment and use disposable plates. We do have 24/7 nurses at the facility, and we check frequently the positive resident.’’ In addition, LPA asked the Executive Director if the facility was following PIP (Proper Infections Precautious). Does the facility have an emergency plan in place for an infectious outbreak? Is your staff trained to follow PIP? Would your staff follow PIP (Proper Infections Precautions) during an outbreak? He answered yes to all the questions. Evaluation Report continues LIC 9099-C During interviews with staff (S#1-S#11), (11) out of (11) stated that currently there is not an outbreak at the facility, and the protocol when it comes to following proper infection precautions is the following: Once a resident tested positive, we quarantine the resident then we put a PPE station outside their room then we informed their physician and family members then we do contact tracing and disinfection of surfaces. After the sixth day, they can leave their room if they are not showing symptoms. Also, (11) out of (11) staff stated that the facility is following proper infection precautions, has an emergency plan in case of an infectious outbreak, is trained in following proper infection precautions, and would follow the steps. During interviews with residents (R#1-R#11), (10) out of (11) residents stated that the facility does a good job when it comes to following proper infection precautions, and they have seen staff wearing masks in the past or when needed. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted, and a copy of the Complaint Report was given to Ralph Balbin /Executive Director.the state’s words, verbatim · CDSS document, Jan 5, 2024 · control 11-AS-20231229084545

Type of visit: Required - 1 Year

On 10/14/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Executive Director Ralph Balbin. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to serve (150) non-ambulatory elderly residents of which (30) may be bedridden ages 60 and above. The facility is approved for (20) hospice residents. Currently, the facility has (16) hospice residents. The facility is a three-story structure located in a residential neighborhood. It consists of the following: (27) resident bedrooms in the Neighborhood and (114) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, a lobby, a living room, (3) lounge areas, a dining room, a kitchen, a bistro, a Memory Care Unit. housekeeping/janitorial storage closets, (3) administrative offices, (2) laundry rooms, an activity room, a Wellness room, an engineering office, a beauty salon, an activity area, front and rear patio area, a gated pool, and outdoor storage sheds. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #135, #138, #245, #253, #322 and #330. All call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.7 – 115.4 degrees F. A comfortable temperature was maintained in the facility at 72 - 74 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. (Evaluation Report continues LIC 809-C) Fire extinguishers were fully charged, and smoke detectors and carbon monoxide were operable in each resident's room. The facility conducted an emergency fire and earthquake drills on 09/20/23. The facility has certificate of liability insurance effective 10/01/23 - 10/01/24. The facility is current on annual (CCL) license fees. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurate. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#6 (S1-S6) personnel files were in maintained in place. LPA conducted (5) residents and (3) staff interviews. Deficiency: During staff file review between 12:30pm - 2:30pm, the following required items were not in the files: (3) out of (6) staff #2, #4, #5 care staff did not have have current CPR/First aid on file. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D). An exit interview conducted with Ralph Balbin, and a copy of the report and appeal rights provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *the state’s words, verbatim · CDSS document, Oct 14, 2023