306005563-3-20-2024-22-AS-AORZ-D3PMRE-20240325095014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005563
Report Date: 03/20/2024
Date Signed: 03/20/2024 02:42:06 PM

Unsubstantiated

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
07/11/2023 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20230711102555

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:	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:	Rosa Ayala		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff failed to provide care and supervision which resulted in resident sustaining injuries during elopement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including Physician Report, Resident Service Plan, Orange County Sheriff’s Report, Orange County Death Certificate and Mission Hospital Medical Records. The purpose of today’s visit is to follow up on an investigation conducted by the Department regarding the above allegation. The investigation conducted revealed the following:
Resident 1 (R1) was admitted to the facility on April 30, 2023. Physician report dated April 25, 2023, notes that R1 had a diagnosis of Dementia.
On July 09, 2023, R1 sustained a fall from their bedroom window located on the second floor of the facility. Surveillance video obtained from Aliso Ridge Behavior Health, which is located across the facility parking lot, captured R1’s attempted elopement. CONTINUED ON LIC 9099C DATED 03/20/2024

Unsubstantiated

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: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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-20230711102555

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: 03/20/2024

NARRATIVE

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Per the video obtained, R1 can be seen knocking the screen out of the window and climbing halfway out the window. R1 then climbed out onto the small ledge beneath the window and turned around to jump to the ground. At approximately 6:41 PM cameras observed a shadow seen falling out the side of the building. At approximately 6:53 PM a staff member found R1 lying on the sidewalk below their bedroom window. Resident records obtained did not note R1 had a history of suicidal ideation. Interviews with five of seven staff reported R1 had a history of wandering and attempted elopement. Orange County Coroner Report lists R1’s cause of death as Hemopneumothorax, Rib Fracture and Traumatic fall.
Per facility policy, windows in the facility memory care are fixed to open no more than eight inches to allow fresh air into the rooms for residents. All exit leading doors are equipped with auditory alarms and delayed egress to alert staff of attempted elopements.

Although R1 sustained a traumatic fall resulting in their death, a review of records obtained and interviews conducted determined that R1’s injuries were not sustained as a result of neglect by the facility staff. Evidence obtained indicates more than likely that R1 was unaware of the consequences of their actions and likely fell while attempting to leave the facility.

Therefore, based on interviews conducted and documents reviewed, the allegation that staff failed to provide care and supervision which resulted in resident sustaining injuries during elopement is 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 violation occurred.

An exit interview was conducted, and a copy of this report and confidential names list was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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