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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005563
Report Date: 02/28/2022
Date Signed: 02/28/2022 03:56:54 PM


Document Has Been Signed on 02/28/2022 03:56 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: 100DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Rosalie SullivanTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Rosa Ayala has a current administrator certificate expiring on 10/23/2022.
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At 1:00 PM, LPA toured the facility with Regional Operations Specialist (ROS) Rosalie Sullivan. Facility has 100 residents in care during today's visit with 5 residents on hospice care. Facility consists of 62 residents in Assisted Living and 38 residents in Memory Care. LPA observed multiple activity rooms, salon, fitness center, and a secured swimming pool. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility provides activities throughout the day including exercise, cooking, gardening, movies and games. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Rooms are a combination of single and double occupancy. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes an electronic sign in/ questionnaire sheet. Facility takes resident and staff temperatures daily and documents. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. Facility has emergency evacuation chairs at the top of stairwells. LPA observed an ample supply of emergency food. LPA observed multiple outside visitation areas. LPA observed the Wellness Center and facility uses electronic medical records for medication management. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. Most residents and all staff are vaccinated for Covid-19.
LPA consulted with ROS regarding placement of the "Let Us No" poster as well as the importance of maintaining an ample supply of emergency water on-site.

No deficiencies noted during today's visit. An exit interview was 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: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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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