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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005563
Report Date: 10/19/2022
Date Signed: 10/19/2022 02:41:01 PM

Document Has Been Signed on 10/19/2022 02:41 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: 105DATE:
10/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rosa Ayala and Allan MacabitasTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to the facility to follow up on facility's enrollment in the "Safely You" program. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the visit, LPA toured the memory care unit which utilizes the cameras. There is not video surveillance signage outside any of the rooms. LPA reviewed camera footage which does not have any audio recording. The cameras are utilized for falls that occur. The recording is only visible to facility staff for 10 minutes before and after the fall. LPA reviewed consents for cameras during the visit. Facility has 24 out of 27 consents for camera usage.










Based on the observations and interviews made, 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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Document Has Been Signed on 10/19/2022 02:41 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/19/2022 at 02:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2022
Section Cited
CCR
87468.2(a)(1)

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In addition to the rights listed in Section 87468.1, residents in.. residential care facilities for the elderly shall have all of the following personal rights: To have a reasonable level of personal privacy....This requirement is not being met as evidenced by:.
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Facility to post video surveillance and obtain all consents for cameras and forward proof to LPA by POC due date.
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Based on observation, Licensee failed to ensure residents are afforded privacy. Facility is in the "Safely You" program and is not fulfilling guidelines for the program. Facility does not have video surveillance signage posted nor all consents required. LPA observed 24/27 consents. This poses a potential health and safety risk.
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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 Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022


LIC809 (FAS) - (06/04)
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