Belmont Village la Jolla.

(Cont. from LIC 9099) Records review of R1's physician's report revealed diagnoses of irritable bowel syndrome, and care plan revealed that R1 required assistance with changing continence products and personal hygiene. Communication logs from 04/10/2026–04/29/2026 showed frequent toileting checks, regular assistance with continence changes, and ongoing wellness checks. Review of R1's care plan notes indicated that staff reported the irritation, a follow-up medical appointment occurred, and treatment instructions were implemented. A physician’s order dated 04/27/2026 attributed the skin irritation to the resident’s gastrointestinal episode and directed increased care for R1. LPA observed R1 clean and well-groomed. LPA attempted to interview R1, however due to cognition, R1 did not qualify for further interview. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate the allegation and therefore deemed unsubstantiated. An exit interview was conducted with Executive Director James Arp. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.

(Cont. from LIC 9099) Regarding the allegation that neglect resulted in a resident sustaining unexplained injuries, interviews did not corroborate the allegations. Interviews with facility staff and outside sources consistently described R1 as having fragile skin, a history of frequent falls, and episodes of combative and resistive behavior. Interviews stated that R1 was often combative during care, exhibited paranoia upon admission, and would swing their arms into objects, causing skin tears and often reopened previously dressed wounds. Staff reported that R1's hospice provider visited twice weekly to provide wound care, and both hospice and facility staff provided ongoing dressing changes throughout R1's time at the facility. Outside source interviews stated that R1 experienced multiple falls, and had skin tears that were not related to abuse or neglect but instead were consistent with R1’s condition and behaviors. Records review of R1's physician's report revealed that R1 had advanced dementia with recent significant progression and had a high fall risk. The report documented episodes of refusal of care, verbal aggression, and the need for fall-prevention measures. Records review of Hospice visit notes documented almost daily falls due to R1's difficulty rising from seated positions. Visit notes also documented ongoing paranoia and aggression, including an incident in which R1 struck a caregiver. No evidence supports that R1's injuries resulted from neglect. Injuries were consistent with the resident’s diagnosis, behaviors, fall history, and skin condition. Regarding the allegation that staff overdosed R1, interviews and records review did not support that staff over-medicated R1. Interviews reported that R1 exhibited significant anxiety, agitation, and aggressive behaviors, and that all medications were administered under hospice orders. Hospice ordered the facility to adjust dosages of R1's medication based on R1's response and any side effects. Interviews stated that R1 was prescribed Lorazepam for anxiety and shortness of breath, and that sedation and reduced activity were known side effects. (Cont. on LIC 9099-C pg. 1) 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 (Cont. from LIC 9099-C) Records review of the Medication Administration Record showed that R1 received lorazepam on an as-needed basis, with no more than one administration per day, and often administered non-consecutively. The prescribed order instructed staff to administer one tablet every four hours as needed. Records review of R1's hospice visit notes revealed that hospice initiated trials of certain medications to address the resident’s significant agitation and anxiety, and dosages were adjusted accordingly when sedation or other side effects were observed. R1's responsible party requested that one trial medication be discontinued, and hospice discontinued the medication accordingly. No evidence corroborates concerns that staff administered medication inappropriately or beyond what was ordered. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director James Arp, whose signature below confirms receipt of these rights.

Purpose of Visit: Incident Follow-Up – Death of Resident Licensing Program Analyst (LPA) Renita Hall conducted an unannounced case management visit to follow up on an incident reported to Community Care Licensing.  LPA met with the Executive Director and the Director of Resident Care and discussed the purpose of the visit. This report documents the follow-up related to the death of Resident 1 (R1). A review of records indicates that R1 was assessed on 03/26/2025 and determined to be independent and not requiring assistance. A Physician’s Report dated 04/25/2025 documented that R1 was 89 years old with a diagnosis of Atrial Fibrillation (A-Fib). The report noted no physical or mental health limitations, no diagnosis of dementia, and that R1 was able to communicate needs, follow instructions, self-administer medications, ambulate independently, and transfer independently. R1 was able to leave the community unassisted and was in good physical health. Continued on 809C 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 Facility notes dated 12/11/2025 reflect that R1 remained independent with ambulation, was physically in good condition, worked with a personal trainer once per week, required no redirection, and was actively engaged in community social activities. On 12/26/2025, records indicate that R1 experienced a fall in their apartment and struck the back of their head. No bleeding was noted. R1 was taking Xarelto, a blood thinner. Emergency services were contacted, and R1 was transported to the hospital via 911 for further evaluation. R1 was evaluated and returned to the facility the same day. Staff conducted rounds to make sure R1 was doing well. On 12/30/2025, R1 was found unresponsive in bed by their partner, who contacted the front desk. The nurse on duty assessed R1 and noted no pulse, no heart sounds, and no respirations. R1 was designated as Full Code, and CPR was initiated but was unsuccessful. Emergency Medical Services responded and pronounced R1 deceased on 12/30/2025 at 7:42 a.m. No additional information was obtained during this follow-up. Based on the information gathered, the facility appears to have acted appropriately and in compliance with applicable regulations regarding this incident. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to the Director of Resident Care along with appeal rights (LIC9058 03/22) and an LIC 811.

[Continued from LIC 9099] On April 21st, 2025, R1 was given a 30-day notice from the facility due to failure to follow facility rules, specifically for engaging in verbal abuse against staff and other instances of disruptive behavior in common areas. Initially a cease and desist, dated March 7th, 2025 was provided to R1, however R1's behaviors continued, and the facility issued the 30-day notice. An appeal meeting with R1 was held May 27th, 2025 and on June 6th, 2025 the facility provided R1 with a notice of the denied appeal and an unlawful detainer was filed. File review of over ten (10) staff member statements throughout April and May 2025 revealed a pattern of racial and derogatory statements being made by R1 towards staff. Staff interviews corroborated abusive behavior by R1, as well as multiple outside sources interviewed. The facility followed regulations regarding eviction procedures and failure to adhere to facility policies falls under the list of valid reasons for evictions, per regulation 87224. Regarding the allegation of staff not preventing the development of R1's pressure injuries, review of R1's physician's report (dated September 2024) revealed R1 had no history of skin condition or breakdown and that R1 did not require continuous bed care. Interview with administrative staff revealed R1 had a history of pressure injuries and even had one prior to move in, which delayed R1's official move in as the facility requested the injury be treated and resolved before moving in. Review of R1's medical documents do note a history of stage 1 pressure injuries since 2020. Records reviewed revealed Home Health and Hospice treatment for R1's recurring pressure injuries from 2024-2025. Per staff interviews, though R1 was not formally bed bound (R1 is noted to be non-ambulatory on their physician's report) they spent most of their time in bed. Two (2) staff interviews corroborated that R1 had periodic sores in their genital area and facility staff would assist with applying ointments to the affected area(s) per instruction from Home Health. Home Health visit records note instructions for facility staff in care for the wounds. Interview with an outside source medical professional revealed that R1's diagnosed condition of Renal Disease contributes to the development of the pressure injuries. This interview also corroborated that facility staff assist in care for the injuries and keep the area clean. [Continued on LIC 812-C] 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 [Continued from LIC 812-C] Regarding the allegation of staff not ensuring R1's incontinence care needs are being met, this is also entwined with the allegation of staff not answering R1's pendant calls in a timely manner. Per the complaint, R1 would regularly wait over an hour and a half for staff to respond to their pendant calls and that R1 has sat in their feces for nearly four hours before staff changed their briefs. Multiple staff and outside source interviews revealed that R1 tends to "exaggerate" their claims on how long it takes to be tended to, when in reality it's only been several minutes. Two (2) staff interviews revealed that R1 specifically calls around shift changes in order to know who is working. Per staff interviews, during shift changes there is a brief staff meeting to pass over information, which then can cause a slight delay in responding to calls during that time. Staff interviews revealed that as R1 is a two (2) person assist, it can take additional time for a secondary staff member to assist on a call if they are assisting someone else at the moment, one (1) mentioning that it on average takes up to 20 minutes to assist R1. The outside source medical professional interviewed revealed that there was no physical indication of R1 having been sitting in their stool for long periods of time as it would've been apparent on R1's pressure injuries. This interview also revealed that as R1 is fully incontinent, they cannot feel when they have had a bowel movement. Other residents interviewed revealed no concerns about the timeliness of staff responses to pendant calls or the speed of incontinence care. File review of R1's Needs & Services plan reveal that staff provide 3-4 brief checks per shift. File review of call button response logs for R1 for a span of three (3) months reveal that R1 utilized their call button on average ten (10) to fifteen (15) times a day and that the majority of calls were resolved within 25 minutes. However, on several occasions response times exceeded an hour, with two (2) being over 2 hours. Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. 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.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director James Arp and Assistant Executive Director Donnie Johnson. Community Care Licensing received an Incident Report on 8/6/25 in which it was reported that on 7/20/25 staff responded to a resident fall. Per the report, the resident, identified as R1, was found sitting on the floor with a laceration to the head and a bruise with swelling on the right lower extremity. Emergency services were contacted and R1 was taken to the hospital where they were treated for a C2 fracture, nose fracture, and right ankle fracture. R1's Responsible Party and Primary Care Physician (PCP) were notified. During today's visit, LPA conducted file review, interviews, and provided consultation with Executive Director Arp. A health and safety visit with R1 could not be conducted as R1 has since passed away. No Deficiencies were cited during the visit as the facility responded accordingly and appropriately. An exit interview was conducted with Executive Director Arp to whom a copy of this report was provided. Their signature below confirms receipt of this document.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to offer an Amended Report for a complaint visit conducted on 8/8/2025. LPA met with Executive Director (ED) James Arp and Assistant Executive Director Donnie Johnson and informed them of the purpose of LPA's visit. During today's visit, LPA obtained Executive Director Arp's signature on the amended report LIC 9099 (10/8/2025). ED Arp was also provided a copy of the amended report. 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.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Associate Executive Director (AED) Donnie Johnson. The facility's license shows a maximum capacity of 220 non-ambulatory residents, of which 100 may be bedridden. All rooms are approved for bedridden and the facility is approved for delayed egress on floors 2, 3, 4, and 5. Additionally the facility has an approved hospice waiver for 20. During today’s inspection there were 171 residents in care. LPA, accompanied by AED Johnson and Building Manager John Miller, toured the interior and exterior of the facility and inspected common areas as well as a sample of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms inspected contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sinks tested on floors 4, 5, 8, 11, 14, 15, and 16 temped at 106.6, 105.2, 105, 105, 108.6, 105.2, and 106.5F, respectively. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Kitchen staff demonstrated precautions taken for dietary restrictions. Cooking, dining equipment, and utensils were present. Knives were stored in areas inaccessible to residents. [Continued on LIC 809-C] 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 [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Laundry areas were noted to be locked or if they were in use and doors opened, staff were present to monitor. Medications were labeled, as required, and stored in locked areas. Med room staff demonstrated to LPA medication administration procedures and LPA also observed med room staff pass medications to residents. A pool exists on the premises. LPA observed the pool to have a surrounding gate per regulation and gates noted to be secured. Per interview with AED Johnson and Building Manager Miller, only staff have keys to the gates and residents who check out keys are monitored by staff while in the pool area. Per AED Johnson, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, fire sprinkler system, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. Most recent emergency drill conducted with staff was held on 6/26/25 for the topics of earthquakes and fires. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA observed residents engaged in facility led activities, particularly in the Connections for Living and Memory Care units. Various calendars and postings throughout common areas of the facility noted various scheduled activities and events. LPA observed various staff and resident interactions throughout their visit and noted residents to be attended to quickly and treated with respect. LPA interviewed 2 staff and 2 clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. LPA did provide a Technical Assistance for best practices on ensuring 1st Aid/CPR Certificates were current and valid. No deficiencies were cited during the inspection. An exit interview was conducted with Associate Executive Director Johnson to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

Licensing Program Analyst (LPA) Sabel Martinez conducted a case management visit to obtain signatures and deliver an amended 9099D form. The LPA met with Assistant Executive Director Donnie Johnson, introduced himself and disclosed the purpose of the visit. Executive Director James Arp arrived during the visit. During the visit, the LPA secured signatures and delivered an amended 9099D form. An exit interview was conducted with Johnson and Arp, to whom a copy of the this report, and Licensee Rights (LIC 9058), were provided via email.

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management - Incident visit. The LPA introduced himself and discussed the purpose of the visit with Executive Director James Arp. Nursing Director Cat Tomboc and Assistant Executive Director Donnie Johnson assisted the LPA during the visit. Today's visit was in response to an LIC624A Death Report, which the licensee self submitted to the CCLD San Diego Regional Office (received on 1/28/2025). [See LIC 811 Confidential Names List for a description of Resident # 1 (R1).] During today’s visit, the LPA conducted a tour of the facility, conducted interviews, and collected pertinent records. A death certificate for R1 was also requested during the visit. No immediate health and safety concerns were observed during today's visit and no deficiencies were cited. An exit interview was conducted with Johnson, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058), were provided.

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Director of Resident Care Services, Cat Tomboc. The facility was licensed for a capacity of two hundred twenty (220) non-ambulatory residents, of which one hundred (100) may be bedridden. The facility was also approved a hospice waiver for twenty (20) residents. Floors # 2, # 3, # 4, and #5 were approved for delayed egress. A secured perimeter was also approved. The LPA, accompanied by staff, toured the interior of the facility. The facility was clean, sanitary, and in good repair. Pathways were free of obstructions and slip hazards. Residents bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Pull cords were tested randomly to confirm the signal system in different floors was operational. Sufficient space was observed for resident activities, meetings, visitation, and laundry. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment, utensils, and emergency supplies were present. There were no toxic chemicals/poisons accessible to clients, and medications were labeled, and stored in a locked area. The LPA reviewed resident and staff records. Due to time constraints, a continuation visit on a subsequent day is necessary to complete the annual inspection. No deficiencies were observed, nor cited on today's date. An exit interview was conducted with Director Tomboc, to whom a copy of this report, and Licensee/Appeal Right (LIC 9058), were provided.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Resident Service Director Cat Tomboc during the visit. Today's visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 01/31/2024 as well as self-reported incident report received at the CCLD San Diego Regional Office on 1/15/2024 and 1/31/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the self-reported death document, R1 passed away on 01/30/2024. During today’s visit, LPA performed a brief facility tour and welfare check on remaining residents, finding no safety concerns. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff. The Death Certificate was also requested during the visit. No deficiency was cited at the time of the visit. An exit interview was conducted with Resident Service Director Cat Tomboc, whose signature below confirms receipt of a copy of this report, the LIC811 and the Licensee Rights (LIC 9058 01/16).

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with executive director James Arp and director of resident care Cat Tomboc. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 8/25/2023). According to the LIC624: on 8/24/2023, Client #1 (C1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of C1.} C1 returned to the facility unharmed on 8/24/2023. During today’s visit, LPA performed a facility tour / welfare check, collected records, and interviewed C1 and staff. According to C1’s latest LIC602 Physician’s Report (dated 6/29/2023) their doctor determined that C1 was not able to safely leave the facility unassisted. Interviews and records showed that Licensee had a written Absentee Notification Plan as part of C1’s record of care, and that staff followed this plan. No deficiencies were cited for this incident. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Tomboc, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.