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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005563
Report Date: 07/15/2022
Date Signed: 07/15/2022 02:45:00 PM

Substantiated


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
06/22/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220622095107
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: 99DATE:
07/15/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rosa AyalaTIME COMPLETED:
03:08 PM
ALLEGATION(S):
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Resident eloped from facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by Executive Director Rosa Ayala and explained the reason for the visit.
During the course of the investigation, LPA interviewed staff and witnesses, toured the facility and reviewed and obtained pertinent documentation such as physician report and facility notes. Regarding the allegation that resident eloped from facility, the investigation revealed the following: On 06/21/2022, Resident 1 (R1) was brought to the facility by Orange County Sheriff at approximately 9:25 PM. Facility was unaware R1 had left the facility. Camera footage indicated the resident had walked out the front door of the facility at 7:37 PM while reception staff was away from the front desk. Facility front door locks at 8:00 PM. Resident was assessed to have no injuries. Per physician report dated 01/27/2022, R1 is unable to leave the facility unassisted. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. CONT ON LIC 9099C DATED 07/15/2022



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: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
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 5
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
06/22/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220622095107

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: 99DATE:
07/15/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rosa AyalaTIME COMPLETED:
03:08 PM
ALLEGATION(S):
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2
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9
Facility is understaffed
Facility is not providing care and supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by Executive Director Rosa Ayala and explained the reason for the visit.
During the course of the investigation, LPA interviewed staff and witnesses, toured the facility and reviewed and obtained pertinent documentation such as physician report and facility notes. Regarding the allegations that facility is understaffed and facility is not providing care and supervision, the investigation revealed the following: Normal facility staffing is four caregivers, one med-tech, and one nurse on 1st and 2nd shift in the assisted living and with two caregivers, one med-tech and one nurse on the NOC shift. There is an additional caregiver daily for Circle of Friends. On the day R1 eloped out of the facility, one caregiver called out on the 2nd shift. Two out of two caregivers interviewed indicated no issues with staffing and the caregivers work as a team. Administrator indicated staffing issues are filled by agency as needed. Facility provided proof of staff schedule which matched the typical facility staffing. R1 is in the "Circle of Friends" at the facility. Caregivers provide escorting and assistance to residents in the group. CONTINUED ON LIC 9099C DATED 07/15/2022
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20220622095107
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: 07/15/2022
NARRATIVE
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Two out of two staff, Administrator, and R1 state resident periodically refuses to be escorted to activities and refuses showers. Facility provided written documentation of such refusals. Due to conflicting information, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator and a copy of this report was provided to facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 22-AS-20220622095107
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: 07/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2022
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 conduct an elopement in-service and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure R1 was provided care and supervision. R1 eloped out of the facility and staff were unaware the resident was gone. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.
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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: 07/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20220622095107
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: 07/15/2022
NARRATIVE
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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: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5