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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 04/24/2025
Date Signed: 04/24/2025 04:32:32 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2025 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20250414155636
FACILITY NAME:BELMONT VILLAGE RANCHO PALOS VERDESFACILITY NUMBER:
198601646
ADMINISTRATOR:BALBIN, RALPHFACILITY TYPE:
740
ADDRESS:5701 CRESTRIDGE RDTELEPHONE:
(310) 377-9977
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:150CENSUS: 130DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ralph Balbin, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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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
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 11-AS-20250414155636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES
FACILITY NUMBER: 198601646
VISIT DATE: 04/24/2025
NARRATIVE
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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

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20250414155636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES
FACILITY NUMBER: 198601646
VISIT DATE: 04/24/2025
NARRATIVE
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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

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20250414155636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES
FACILITY NUMBER: 198601646
VISIT DATE: 04/24/2025
NARRATIVE
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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

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20250414155636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES
FACILITY NUMBER: 198601646
VISIT DATE: 04/24/2025
NARRATIVE
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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.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6