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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005563
Report Date: 11/29/2023
Date Signed: 11/29/2023 03:22:20 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
11/21/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20231121140704
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
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rosa AyalaTIME COMPLETED:
03:04 PM
ALLEGATION(S):
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-Facility failed to provide resident's records to authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the investigation, LPA interviewed Executive Director as well as reviewed and obtained documentation such as request letter for documents. Regarding the allegation that facility failed to provide resident's records to authorized representative, the investigation revealed the following: Facility received a request for Resident 1's (R1) records dated 11/16/2023 and received via Federal Express 11/17/2023. Facility indicated working on submitting records as of today, 11/29/2023 but that the records had not been submitted to date. Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore the above allegation is 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.
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: 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.
LIC9099 (FAS) - (06/04)
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Control Number 22-AS-20231121140704
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: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
HSC
1569.269(a)(21)
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Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days..This req is not being met as evidenced by:
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Licensee to submit requested records to resident's agent and forward proof to LPA by POC due date.
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Based on records reviewed, Licensee failed to submit requested documents to resident's agent. This poses a potential health and safety risk to residents in care.
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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: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
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