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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005563
Report Date: 11/29/2022
Date Signed: 11/29/2022 03:52:38 PM


Document Has Been Signed on 11/29/2022 03:52 PM - It Cannot Be Edited

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:AYALA, ROSAFACILITY TYPE:
740
ADDRESS:300 FREEDOM LNTELEPHONE:
(949) 643-1050
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92656
CAPACITY:180CENSUS: 109DATE:
11/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:46 PM
MET WITH:Rosa AyalaTIME COMPLETED:
03:41 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Alvaro Ramirez made an unannounced case management visit to follow up on an incident report received by Community Care Licensing on 11/28/2022. LPAs met with Executive Director Rosa Ayala and explained the reason for the visit.

Incident report dated 11/21/2022 indicated Resident 1 (R1) had fallen to the floor after attempting to walk. The fall was captured on video surveillance. Facility LVN assessed the resident and called hospice who came out later that day. Hospice Nurse assessed the resident to be fine and provided pain medication. The next day resident was still in pain and was assessed by Director of Resident Care. R1 was observed to have swelling on the left hip and the leg was observed to be visibly shorter than the other leg. Mobile X-Ray was called out and resident was diagnosed with a broken left hip.

During the visit, LPA Ramirez observed the resident resting comfortably. LPAs reviewed and obtained pertinent documentation such as physician report and hospice notes.







Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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