198601646-5-12-2025-11-AS-SCIS-DL72KR-20250903172817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 05/12/2025
Date Signed: 05/12/2025 11:31:28 AM

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 VERDES		FACILITY NUMBER:	198601646
ADMINISTRATOR:	BALBIN, RALPH		FACILITY TYPE:	740
ADDRESS:	5701 CRESTRIDGE RD		TELEPHONE:	(310) 377-9977
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	150	CENSUS: 128	DATE:	05/12/2025
		UNANNOUNCED	TIME BEGAN:	11:17 AM
MET WITH:	Ralph Balbin, Executive Director		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Staff charged resident for services not rendered

INVESTIGATION FINDINGS:

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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

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

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 3

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: 05/12/2025

NARRATIVE

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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

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 05/12/2025

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	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.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC9099 (FAS) - (06/04)

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