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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005563
Report Date: 11/29/2023
Date Signed: 11/29/2023 03:26:23 PM


Document Has Been Signed on 11/29/2023 03:26 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: 115DATE:
11/29/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Rosa AyalaTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 11/07/2023. LPA were greeted and granted entry into the facility and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87464(f)(4) pertaining to Basic Services has been cleared. Licensee provided proof of correction. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87464(f)(1) pertaining to Basic Services has been cleared. Licensee provided proof of correction. Licensee has complied with the POC.


Licensee has been advised to maintain all areas of facility in compliance.


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: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
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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