Basic services and supervision
Cited in 2 reports, with 2 deficiencies in total.
BELMONT VILLAGE CARDIFF
3535 MANCHESTER AVE, Cardiff By The Sea CA 92007
175 bedsLatest official report Aug 22, 2026Licensed
Additional info
- Telephone
- (760) 436-8900
- Licensee
- BELMONT VILLAGE CARDIFF TENANT & LP; BELMONT THREE
- Administrator
- ASHLEY MARCELLUS
- Contact
- ASHLEY MARCELLUS
- License first date
- Aug 1, 2012
- License effective date
- Aug 1, 2012
- District office
- SAN DIEGO RO · (619) 767-2300
- Regional office
- 08
- Clients served
- 983 - RCFE / DEMENTIA
Summary
The available records show 4 Type A and 8 Type B deficiencies for this facility.
- Most recent inspection
- Aug 22, 2026
- Most recent deficiency
- Feb 22, 2026
3 later reports, from Mar 4, 2026 through Aug 22, 2026, recorded no deficiencies, though the records do not say whether they were follow-ups.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 91 San Diego County facilities licensed for 50 or more beds.
In the available public five-year record, CCLD published 19 reports for this facility: 9 inspections, 9 complaint investigations, and 1 licensing or administrative record.
Those records contain 4 Type A and 8 Type B deficiencies.
0 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 9
- Recorded deficiencies
- 12
- Type A deficiencies
- 4
- Type B deficiencies
- 8
- Substantiated complaints
- 3
- Repeated topics
- 3
About the same as most this size
2 in the last 12 months
Well above the typical 3
10 in the last 12 months
Most this size have none
4 in the last 12 months
Well above the typical 3
6 in the last 12 months
More than the typical 1
2 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Incident reporting
Cited in 2 reports, with 2 deficiencies in total.
Staffing, personnel, and training
Cited in 2 reports, with 2 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations4 substantiated · 0 unsubstantiated · 0 unfounded · 4 cited
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
87411 — Personnel Requirements (sufficient, competent staff to meet resident needs at all times) The following requirement has not been met as evidenced by: On 06/18/2021 during a facility-wide power outage, R1 fell in their apartment and remained on the floor overnight without staff assistance until ~0715 on 06/19/2021. Required welfare checks and timely assistance were not provided, resulting in unmet care needs and contributing to a serious injury later diagnosed at the hospital. which poses an immediate, health, safety, or personal rights risk to residents in care.
Official plan of correction
All direct care staff will receive training on required welfare checks, emergency response procedures, and timely assistance to residents following an incident. Documentation of training will be maintained in personnel files and submit proof to LPA by POC date of 02/23/2026. The Administrator will implement a monitoring system to document completion of welfare checks each shift. The Administrator or designee will conduct weekly audits for 30 days to ensure compliance and ongoing monitoring thereafter.
Deadline recorded: Feb 23, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 23, 2026
Correction not verified in available records
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87464(a)(1)
- Regulation authority
- CCR
What the official deficiency says
87465(a)(1) — Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The following requirement has not been met as evidenced by: Following the known fall on the morning of 06/19/2021, facility staff did not arrange timely medical evaluation for R1. The responsible party transported R1 to the hospital several hours later, where a spinal cord injury was diagnosed. Facility did not ensure prompt medical care was obtained. which poses an immediate, health, safety, or personal rights risk to residents in care.
Official plan of correction
All direct care staff will be retrained on fall protocols, including immediate assessment, documentation, and timely arrangement of medical services when indicated. Training will include when to contact emergency services versus responsible parties.. Documentation of training and monitoring will be maintained at the facility, and submit poof to LPA by POC date of 02/23/2026.
Deadline recorded: Feb 23, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 23, 2026
Correction not verified in available records
Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87303(d)
- Regulation authority
- CCR
What the official deficiency says
87212 Emergency Disaster Plan (a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available. The following requirement has not been met as evidenced by: The facility did not have emergency adequate lighting in resident 1's room possibly contributing to a fall sustaining injuries, which poses an immediate health, safety, or personal rights risk to residents in care.
Official plan of correction
The Administrator will conduct a facility-wide inspection to ensure all emergency lighting fixtures are operational and sufficient to ensure resident safety. Any deficiencies will be corrected immediately.Staff will be instructed to promptly report non-functioning or inadequate lighting to management. The Administrator or designee will monitor emergency lighting conditions during monthly safety checks to ensure ongoing compliance, and send Emergency disaster plan to LPA by POC date of 02/23/2026.
Deadline recorded: Feb 23, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 23, 2026
Correction not verified in available records
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211
- Regulation authority
- CCR
What the official deficiency says
87211 — Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: The following requirement has not been met as evidenced by: The facility did not timely report R1’s fall, overnight time on the floor, or subsequent hospitalization to the licensing agency. Supervisory staff were also not promptly notified of the outage and incident until contact by the responsible party the following day, which poses a potential, health, safety, or personal rights risk to residents in care.
Official plan of correction
All staff will receive retraining on identifying reportable incidents, required timelines, and proper notification procedures, including notifying the licensing agency, supervisory staff, and responsible parties without delay. Documentation of training will be maintained in personnel files and send proof to LPA by POC date of 03/08/2026.
Deadline recorded: Mar 8, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 8, 2026
Correction not verified in available records
Complaint
Allegations6 substantiated · 3 unsubstantiated · 0 unfounded · 6 cited
Incident reportingType A
- Official classification
- Type A
- Official code
- 87211(a)(1)(D)
- Regulation authority
- CCR
What the official deficiency says
87211(a)(1)(D) Reporting Requirements – “The licensee shall report by telephone to the licensing agency, local law enforcement, and the responsible person any suspected physical abuse … immediately, or within 24 hours.” The following requirement has not been met as evidenced by: Based on record review, the facility failed to immediately notify law enforcement when Resident #1 disclosed possible sexual abuse on 03/09/22. Law enforcement was not contacted until 03/10/22. This posed an immediate health and safety risk to all residents in care.
Official plan of correction
The licensee shall ensure that all suspected physical or sexual abuse is reported immediately, or within 24 hours, to the licensing agency, local law enforcement, and the resident’s responsible party, as required by Title 22 CCR §87211. The licensee shall review and revise its abuse reporting procedures to ensure immediate notification occurs. All staff shall receive training on mandated reporting requirements and timelines. Documentation of reports shall be maintained in resident files and submitted to LPA by POC date of 02/23/2026.
Deadline recorded: Feb 23, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 23, 2026
Correction not verified in available records
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(a)
- Regulation authority
- CCR
What the official deficiency says
87463 Reappraisals – “The licensee shall arrange a meeting with the resident and/or representative when a significant change occurs in the resident’s condition to determine if the facility can continue to meet the resident’s needs.” The following requirement has not been met as evidenced by: Based on file review, residents with dementia and wandering behavior were moved from memory care into assisted living without evidence of reappraisal, while continuing to require memory care services. This resulted in residents not being placed at the appropriate level of care, which poses a potential, health, safety, or personal rights risk to residents in care.
Official plan of correction
The licensee shall ensure a reappraisal is conducted whenever a significant change occurs in a resident’s physical, mental, or functional condition. The licensee shall review procedures to ensure residents and/or their responsible representatives are included in the reappraisal process. Staff responsible for assessments shall be trained on identifying significant changes in condition and completing timely reappraisals. The licensee shall implement ongoing monitoring to ensure residents are placed and maintained at the appropriate level of care based on current reappraisals and send proof to LPA by POC date of 03/08/2026.
Deadline recorded: Mar 8, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 8, 2026
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. The following requirement has not been met as evidenced by: Based on record review, residents reported not receiving assistance consistent with their care needs. This poses a potential, health and safety risk to residents in care.
Official plan of correction
The licensee shall ensure sufficient staff are scheduled at all times to meet residents’ care and supervision needs. The licensee shall review staffing patterns in relation to resident acuity and adjust staffing as necessary. Staff shall be trained to provide care consistent with residents’ assessed needs. The licensee shall implement ongoing oversight to ensure residents receive timely assistance and send proof to LPA by POC date of 03/08/2026.
Deadline recorded: Mar 8, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 8, 2026
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.2(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, 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 and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The following requirement has not been met as evidenced by: Based on record review, residents reported being left in wheelchairs all day. This poses a potential, health and safety risk to residents in care.
Official plan of correction
The licensee shall ensure residents are treated with dignity and are not left seated for prolonged periods without appropriate repositioning, assistance, or activity consistent with their assessed needs. Staff shall be trained on residents’ personal rights and mobility assistance requirements. The licensee shall review resident care plans to ensure mobility and repositioning needs are clearly identified and implemented, and send proof to LPA by POC date of 03/08/2026.
Deadline recorded: Mar 8, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 8, 2026
Correction not verified in available records
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87507
- Regulation authority
- CCR
What the official deficiency says
87507 Admission Agreement – “All basic and optional services, rates, and charges shall be specified in the admission agreement. The licensee shall not charge for services that are not provided.” The following requirement has not been met as evidenced by: Based on documentation, residents were charged for memory care services and the “Circle of Friends” program despite not receiving or attending such services. This violates the admission agreement and created a financial burden on residents, which poses a potential, health, safety, or personal rights risk to residents in care.
Official plan of correction
The licensee shall ensure residents are charged only for services that are specified in the admission agreement and actually provided. The licensee shall review all current admission agreements and billing records to verify accuracy. Any billing discrepancies shall be corrected. Administrative staff responsible for billing shall be trained on admission agreement requirements and appropriate billing practices. The licensee shall implement ongoing monitoring of billing records to ensure continued compliance and submit proof to LPA by POC date of 03/08/2026.
Deadline recorded: Mar 8, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 8, 2026
Correction not verified in available records
Basic services and supervisionType B
- Official classification
- Type B
- Official code
- 87464(a)(2)
- Regulation authority
- CCR
What the official deficiency says
87464(a)(2) Basic Services – Personal Care and Supervision – “Basic services shall at a minimum include: (2) Personal assistance and care as needed by the resident … including assistance with bathing, grooming, dressing, mobility, and other personal needs.” The following requirement has not been met as evidenced by: Based on record review, residents reported not being assisted with showers. This poses a potential, health and safety risk to residents in care.
Official plan of correction
The licensee shall ensure residents receive personal care assistance, including assistance with bathing and hygiene, as needed. Staff shall be re-trained on providing and documenting personal care services in accordance with residents’ assessed needs. The licensee shall review resident care plans to ensure required personal care services are identified and implemented. Ongoing supervision and periodic audits shall be conducted to ensure residents’ personal care needs are consistently met. and proof submitted to LPA by POC date of 03/09/2026.
Deadline recorded: Mar 9, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 9, 2026
Correction not verified in available records
Complaint
Allegations0 substantiated · 4 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 2 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(12)
- Regulation authority
- CCR
What the official deficiency says
Personal Rights of Residents in All Facilities.Residents in all residential care facilities for the elderly shall have all of the following personal rights:To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money.This requirement is not met as evidenced by: Based on interviews conducted, 1 out of 139 residents’ furniture was discarded without permission from the resident or RP in April 2020. Therefore, posing a potential personal rights risk to residents in care.
Official plan of correction
Facility has a policy in place regarding residents items. The facility staff is not allowed to get rid of residents items without written/verbal consent along with documentation. Administrator will provide the policy to CCL by POC due date 01/14/2022
Deadline recorded: Jan 14, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jan 14, 2022
Correction not verified in available records
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology