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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005563
Report Date: 02/04/2025
Date Signed: 02/04/2025 04:34:28 PM

Document Has Been Signed on 02/04/2025 04:34 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BELMONT VILLAGE ALISO VIEJOFACILITY NUMBER:
306005563
ADMINISTRATOR/
DIRECTOR:
AYALA, ROSAFACILITY TYPE:
740
ADDRESS:300 FREEDOM LNTELEPHONE:
(949) 643-1050
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92656
CAPACITY: 180TOTAL ENROLLED CHILDREN: 0CENSUS: 134DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:31 AM
MET WITH:Rosa AyalaTIME VISIT/
INSPECTION COMPLETED:
04:48 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias made an unannounced visit to conduct the required annual inspection. LPAs met with Executive Director (ED) Rosa Ayala and explained the reason for the visit. The facility is a three story building which consist of 30 units on the first floor reserved for memory care residents, and 16 additional units on the second floor for memory care residents. The capacity of the facility is 180 non-ambulatory and a hospice waiver for thirty five and bed ridden waiver for thirty five. There are currently a total of 134 residents, 46 of them are in memory care, and 14 on hospice. Rosa Ayala's Administrator's Certificate is in process of renewal as of 12/23/24. LPAs observed the PUB 475 poster (See Something, Say Something Poster) posted by the resident mail box. The PUB 475 poster posted is 20" X 26." LPAs observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPAs observed the emergency food and water. LPAs and ED toured resident rooms on three floors of the facilities. LPAs and ED toured the resident rooms in memory care unit area. LPAs inspected twelve resident rooms. All resident rooms had the required furnishings. All resident bathrooms were clean and operational. At 9:58am, one out of twelve resident rooms observed had PRNs in the bathroom. LPAs tested the emergency alarms and observed the staff came promptly when alerted. The hot water in the twelve resident rooms inspected measured 112.4 degrees Fahrenheit to 117.3 degrees Fahrenheit. LPAs observed residents participating in exercises in the activities room in the memory care area. There is fitness room and activities room for all residents. There is an outdoor courtyard for residents to sit outside. In the outside area there is a garden for residents to plant things. There is a pool area secured with a gate. Residents can utilize the pool as long as they are accompany with a staff who is water safety certified or a family member. In the summer they have water aerobics. There are fire extinguishers on every floor and all fire extinguishers are fully charged. LPAs observed emergency evacuation chairs in each stairwell. The last emergency fire drill was conducted on 1/29/25. The fire safety system is inspected annual every year by an outside agency, The last inspection was 8/30/24. LPAs reviewed twelve resident files with no discrepancies. All resident files had the required documents.
Continued on LIC-809C 2/4/2025
Alisa OrtizTELEPHONE: (714) 287-4084
Fred AriasTELEPHONE: (714) 703-2840
DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BELMONT VILLAGE ALISO VIEJO
FACILITY NUMBER: 306005563
VISIT DATE: 02/04/2025
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LPAs reviewed five staff files with no discrepancies observed. All staff files reviewed had current CPR/First Aid training.

At around 2:30 PM, LPAs inspected medication and medication administration records (MAR) for selected residents. No discrepancies observed. LPAs observed medications are kept secured in a medication cart that is locked in a medication room. LPAs observed the first aid kits to have all the required components and a first aid book at hand. LPAs interviewed staff and residents. No obstacles or hazards were noted inside or outside of the facility.

Based on the observations made during today's visit, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Fred AriasTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/04/2025 04:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, a bottle of acetaminophen was found in a resident 1's medicine cabinet. The physician's report for this resident stated resident cannot self administer PRN medication which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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Remove noted item and forward proof of correction to LPA by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Alisa OrtizTELEPHONE: (714) 287-4084
Fred AriasTELEPHONE: (714) 703-2840

DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025

LIC809 (FAS) - (06/04)
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