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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005563
Report Date: 06/07/2021
Date Signed: 06/07/2021 11:31:39 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20210602085536
FACILITY NAME:BELMONT VILLAGE ALISO VIEJOFACILITY NUMBER:
306005563
ADMINISTRATOR:LAGMAY, NERISSAFACILITY TYPE:
740
ADDRESS:300 FREEDOM LNTELEPHONE:
(949) 643-1050
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92656
CAPACITY:180CENSUS: 76DATE:
06/07/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Rosa Ayala and Colleen PappsTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff dispensed the incorrect medication to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced 10 day complaint visit to gather information regarding the above allegation. LPA met with Executive Directors Colleen Papp and Rosa Ayala and explained the reason for the visit.
During the course of the visit, LPA interviewed staff and resident, observed medication administration procedures as well as reviewed and obtained pertinent information such as staff training and medication orders. Regarding the allegation that staff dispensed the incorrect medication to resident, the investigation revealed the following: On 05/26/2021, Staff 1 (S1) dispensed the incorrect medication to Resident 1(R1). R1 was given R2's medication. Both R1 and R2 were sitting together at the time of the incident. The error was noted immediately and R1 was assessed and sent out to Kaiser Irvine for observation. R1 returned to the community same day without any adverse affects. S1 indicates verifying the name of R1 but inadvertently administered R2's medication. Facility indicates providing re-training in medication management S1 on 05/26/2021. S1 has a current LVN license expiring on 09/30/2022. The preponderance of evidence standard has been met, CONTINUED ON LIC 9099C DATED 06/07/2021.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
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 22-AS-20210602085536
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 06/07/2021
NARRATIVE
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therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director Ayala and a copy of this report was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20210602085536
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2021
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Licensee to provide retraining to S1 on 06/08/2021. Licensee to provide proof of training by POC due date. Facility conducted retraining of policy and procedure as well as corrective action on 05/28/2021.
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Based on observation and interview, Licensee failed to ensure care and supervision was provided to R1. R1 was inadvertently given seven medications belonging to another resident. R1 was hospitalized for observation. 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: 06/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3