306005563-11-7-2023-22-AS-AORZ-CXYW45-20231127155657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005563
Report Date: 11/07/2023
Date Signed: 11/07/2023 10:02:46 AM

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
02/23/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220223091921

FACILITY NAME:	BELMONT VILLAGE ALISO VIEJO		FACILITY NUMBER:	306005563
ADMINISTRATOR:	AYALA, ROSA		FACILITY TYPE:	740
ADDRESS:	300 FREEDOM LN		TELEPHONE:	(949) 643-1050
CITY:	ALISO VIEJO	STATE: CA	ZIP CODE:	92656
CAPACITY:	180	CENSUS: 115	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	08:47 AM
MET WITH:	Rosa Ayala		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Staff did not give medications timely
Oxygen was not kept on resident according to physicians orders

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 and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as physician report and hospice notes. Regarding the allegations that oxygen was not kept on resident according to physicians orders and staff did not give medications timely, the investigation revealed the following: Resident 1 (R1) admitted into hospice care on 12/02/2021. Hospice orders dated 12/02/2021 indicated an order for oxygen, 2 liters, given continuously and 2-5 liters for shortness of breath. Two out of two staff stated that the resident was agitated and would pull the canula out. However, hospice notes dated 01/14/2022 and 01/19/2022 indicated the oxygen tank was turned off when hospice nurse arrived. Hospice notes indicated that the resident's breathing declined rapidly without the use of oxygen. Additional hospice documentation indicated caregivers were not advising facility when the oxygen tank had run out. CONTINUED ON LIC 9099C DATED 11/07/2023

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220223091921

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: 11/07/2023

NARRATIVE

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R1 was initially prescribed Morphine .25 mg/ml as needed for pain. Per hospice notes dated 01/05/2022 and 01/07/2022, resident is unable to make needs known and unable to verbalize pain. Facility LVN's were the ones providing the Morphine to the resident as needed. Witness indicates expressing to staff that R1 was unable to verbalize pain and would request R1 be given the medication. Resident could be observed to be in pain by moaning and grimacing. Hospice prescribed a new order of Morphine in the morning on 01/26/2022 for Morphine 0.5 mg/ml, three times daily, routine. Per hospice notes, nurse arrived in the evening of 01/26/2022 to ensure medication was being administered. Resident is observed to be in pain with no Morphine administered. Hospice notes stated that Staff 1 (S1) indicated the staff had not received an order even as there was an order for Morphine as needed, still standing. Hospice nurse administered the medication to the resident. Hospice nurse attempted to educate S1 regarding medication orders and the purpose of hospice care and the staff was "Not receptive." The next day, 01/27/2022, Hospice nurse arrived to the facility to discover facility staff had failed to administer routine or as needed Morphine, again, despite education and medication orders. Hospice nurse administered the medication during the visit and resident was put on comfort measures that day. Resident passed away on 01/29/2022. Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore the above allegations are 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 Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220223091921

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: 11/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/08/2023 Section Cited CCR 87464(F)(4)	1 2 3 4 5 6 7	Basic services shall at a minimum include: Personal assistance and care as needed by the resident..., with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications..This req is not being met as evidenced by:	1 2 3 4 5 6 7	Licensee to provide an in-service inconjunction with hospice regarding medication administration and forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on records reviewed, Licensee failed to ensure R1 was being assisted with medication assistance. Per hospice documentation, resident was not receiving prescribed pain management at end of life. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 11/08/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Licensee to provide an in-service on oxygen administration and forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record review, Licensee failed to ensure care was being provided to R1. Per hospice documentation, R1's oxygen was turned off on two different occasions when hospice arrived. R1 was prescribed continuous oxygen. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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 Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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