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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604562
Report Date: 12/18/2025
Date Signed: 12/18/2025 05:59:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2025 and conducted by Evaluator Arian Golbakhsh
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20251215101832
FACILITY NAME:BELMONT VILLAGE LA JOLLAFACILITY NUMBER:
374604562
ADMINISTRATOR:ARP, JAMESFACILITY TYPE:
740
ADDRESS:3880 NOBEL DRIVETELEPHONE:
(858) 450-2500
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:220CENSUS: 187DATE:
12/18/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Executive Director James ArpTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Lack of supervision resulting in resident elopement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to conduct a complaint investigation and delivered findings regarding the above mentioned allegation. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to Executive Director James Arp. Note, LPA did step out for lunch from 12 to 1pm.

On 12/15/2025, the Department received a complaint where it was alleged that a resident, identified as R1, had eloped from the facility due to lack of required supervision. The complaint alleges that R1 was supposed to have 1:1 supervision and did not at time of elopement. The Department’s investigation consisted of an unannounced facility visit, records review, and interviews with residents, staff, and outside sources.

[Continued on LIC 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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 08-AS-20251215101832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE LA JOLLA
FACILITY NUMBER: 374604562
VISIT DATE: 12/18/2025
NARRATIVE
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[Continued from LIC 9099]

On 12/17/25, the Department received an incident report from the facility regarding the elopement of R1. Per the report, the facility had received a phone call from the fire department that the resident was at their fire station. The fire department transported R1 to the hospital for evaluation and was discharged back to the facility same day with no noted injuries.

Per interview with administrative staff, after review of facility camera footage, it was determined that R1 had wandered alone from their unit to the ground floor common area and eloped through a side door by the cafe into the fenced in patio area outside. R1 then exited through the gate leading from the patio to the front entrance and street where staff did not notice R1 wander away. Per administrative staff interview, the external doors and gate were not alarmed during the day.

Per review of R1's records, R1 is diagnosed with Dementia and is unable to leave the facility unassisted. Per R1's assessment and service plan dated November 2025, R1 required escorts while going to meals and activities due to confusion. Additionally, the service plan stated that R1 required redirection and guidance, which is noted to be done through the use of frequent "eyes-on" checks. R1 is also noted to have a score of two (2) on their wander risk, and a comment that R1 "likes to walk outside in the neighborhood at home." Interview with R1's spouse revealed that R1 had attempted to wander off the facility once before but that staff immediately saw and redirected them back into the property.

Based on LPA's review of records, interviews with staff, residents, and outside sources, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D. As this is a violation pertaining to absence of supervision, a Zero Tolerance Violation (ZTV) Civil Penalty is being assessed. The Civil Penalty is being assessed in the total amount of $500.00 and details are noted on the attached LIC 421IM.

An exit interview was conducted with Executive Director Arp to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20251215101832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE LA JOLLA
FACILITY NUMBER: 374604562
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2: In addition to the rights listed in Section 87468.1 [...] residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs
This requirment is not met as evidenced by:
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Licensee will submit a plan of operations in measures/changes made to mitigate elopement risk at the facility and review resident supervision needs. Licensee will submit this to LPA by POC due date.
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Based on file review and interviews, the Licensee did not ensure R1 was supervised as needed, resulting in elopement, posing an immediate health and safety risk to 1 out of 187 residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
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