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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005563
Report Date: 06/29/2023
Date Signed: 06/29/2023 11:47:46 AM


Document Has Been Signed on 06/29/2023 11:47 AM - 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: 104DATE:
06/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Rose AyalaTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Dwayne Mason made an unannounced case management visit to follow-up on an incident report received by Community Care Licensing on 6/21/2023. LPAs met with Executive Director (ED) Rosa Ayala and explained the reason for the visit.

Incident report dated 6/21/2023 indicated that on 6/13/2023 at about 3:00 a.m., Staff 1 (S1) and Staff 2 (S2) reported to Staff 3 (S3) that Resident 1 (R1) had redness to their back side. S3 assessed resident, they was able to move extremities with pain, and reported a 3 on a 1-10 pain scale. Resident stated he fell but could not recall details or timing. Primary Care Physician (PCP) was contacted via email and community was advised to monitor.

During interviews, ED stated that on 6/13/23, R1 had one episode of vomiting and that was also reported to PCP. A record review of emails dated same date, confirm PCP was notified and inquired whether R1 was able to take a deep breath without severe pain. Staff 4 (S4) confirmed via email that R1 was able to take a deep breath without severe pain and was also “able to walk to lunch just fine” and ate breakfast and lunch with “no more episodes of throwing up.” Per ED, R1’s Responsible Party (RP) was contacted by phone, and a general voicemail was left. RP did not return facility’s call and facility staff did not make an additional attempt to contact RP. On 6/17/23, R1 was picked up for an outing with family. During outing discoloration was observed to R1’s lower back on right hand side. Family took R1 to urgent care and it was determined R1 had sustained rib fractures.

During today’s visit, LPAs were unable to interview R1. R1 has not returned to facility following urgent care visit. LPAs interviewed four residents and four out of four were unable to recall observing or hearing R1 fall, and stated they had no concerns regarding falls or staff. Residents are able to call for help with a pendant or pull cord in their bedroom, should they need assistance. Per residents, staff is responsive to their needs. (Cont. LIC809-C)
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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
VISIT DATE: 06/29/2023
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LPAs reviewed and obtained pertinent documentation such as R1’s Physician Report (LIC 602) dated 6/06/23, progress notes for R1 dated 6/6-18/23, email correspondence between facility staff and PCP on 6/13/23, and a picture of R1’s injury taken on 6/13/23. LPA Gutierrez also obtained contact information for S1, S2, S3, and S4 who were not currently present at the facility to be interviewed. LPAs informed ED that subsequent visits and document requests could be required regarding the incident and ED stated they understood.

An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
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