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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005563
Report Date: 04/13/2021
Date Signed: 04/13/2021 04:34:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BELMONT VILLAGE ALISO VIEJOFACILITY NUMBER:
306005563
ADMINISTRATOR:COOLEY, LOGANFACILITY TYPE:
740
ADDRESS:300 FREEDOM LNTELEPHONE:
(949) 643-1050
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92656
CAPACITY:180CENSUS: 67DATE:
04/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Logan Cooley and Colleen PappTIME COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an incident report/ SOC 341 received on 04/13/2021. LPA met with Director of Resident Services Nerissa Lagmay and explained the reason for the visit. Executive Directors Logan Cooley and Colleen Papp arrived during the visit.
Incident report dated 04/12/2021 indicated Resident 1 (R1) reported Staff 1 (S1) came into the resident's room on the morning of 04/12/2021 and put the staff's hand in the resident's underwear. S1 is hired through OC Home Care Services. Upon receiving the information, Executive Director (ED) Logan Cooley reported the information to Community Care Licensing, Ombudsman, and Orange County Sheriff. Deputies responded and interviewed the resident. Deputies indicated to ED they would not be opening a case as no crime had been committed. ED notified OC Home Care Services of the allegation.

During the visit, LPA toured the facility and interviewed R1, staff and 5 additional residents. All residents observed in the facility appeared happy and well taken care of. All 6 residents interviewed stated satisfaction with their health and safety as well as services provided by the facility. LPA observed no documentation of criminal record clearance transfer for S1 and verified through Community Care Licensing Regional Office that S1 is not associated to the facility.
Further investigation required.



Based on the observations made during today’s inspection the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BELMONT VILLAGE ALISO VIEJO
FACILITY NUMBER: 306005563
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2021
Section Cited

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not being met as evidened by:
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Based on observation, Licensee failed to ensure S1's criminal clearance was transferred to the facility. This poses an immediate health and safety risk to 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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2021
LIC809 (FAS) - (06/04)
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