306005563-5-6-2024-22-AS-AORZ-D5PU9Z-20240528152357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005563
Report Date: 05/06/2024
Date Signed: 05/06/2024 03:41:31 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
05/01/2024 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20240501161913

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:	05/06/2024
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Rosa Ayala		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not provide an appropriate sleeping arrangement for a resident
Staff do not provide adequate care and supervision to a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into 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 interviewed staff and resident as well as reviewed and obtained pertinent documentation such as home health documentation. Regarding the allegations that staff do not provide adequate care and supervision to a resident and staff did not provide an appropriate sleeping arrangement for a resident, the investigation revealed the following: Resident 1 (R1) was seen by home health for dermatitis for approximately two months and was discharged from home health on 01/24/2024. Resident has a primary care physician in the San Diego area and stated requesting a physician visit from the Wellness Center in an attempt to find a physician nearby. Resident stated having some swelling on the legs as the resident is prone to Dermatitis. LPA observed resident wearing compression socks and resident stated the socks are worn daily as directed. CONTINUED ON LIC 9099C DATED 05/06/2024

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: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

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-20240501161913

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: 05/06/2024

NARRATIVE

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Resident shares a room with the resident's wife. Resident stated that upon admission, resident shared a queen bed with wife in the facility apartment. A few months later the resident's wife needed a hospital bed and the resident donated the queen bed to charity without informing the facility. Resident indicated pressure from facility to utilize another bed and resident refused. Last week, resident obtained a bed from the facility and LPA observed the bed in the resident's room. Per physician report dated 09/27/2023, Resident is independent and making own decisions. Based on record review and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are 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 was provided to facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC9099 (FAS) - (06/04)

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