306005563-5-14-2026-22-AS-KLYN-DTVSWK-20260508141429

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005563
Report Date: 05/08/2026
Date Signed: 05/14/2026 03:08:47 PM

Document Has Been Signed on 05/14/2026 03:08 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 VIEJO		FACILITY NUMBER:	306005563
ADMINISTRATOR/ DIRECTOR:	AYALA, ROSA		FACILITY TYPE:	740
ADDRESS:	300 FREEDOM LN		TELEPHONE:	(949) 643-1050
CITY:	ALISO VIEJO	STATE: CA	ZIP CODE:	92656
CAPACITY: 180		CENSUS: 138	DATE:	05/08/2026
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Anie Becker		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to deliver findings on an investigation conducted regarding an incident report received by the Department on March 24, 2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. Per the Incident report, on March 17, 2025, Resident 1 (R1) had been found on the floor with a red eye and blood on their nose. 911 was called and the resident was transported to the Hospital where resident was diagnosed with a closed blowout fracture of right orbital floor, fracture of L5 lumbar vertebrae and a fractured rib and left clavicle. The resident moved to Belmont Village Assisted Living on July 31, 2023. Per pre-placement appraisal dated August 03, 2023, R1 required minimal assistance for activities of daily living (ADL’s). Per physician report dated March 24, 2025, R1 had a diagnosis of Parkinson's Disease, Progressive Supranuclear Palsy (A rare, degenerative brain disease that affects movement, balance, and eye control) and had mild cognitive impairment. R1 utilized a walker for mobility. On October 24, 2024, facility staff noticed a change in condition as the resident became more confused and disoriented while becoming progressively unsteady and beginning to have falls. R1 began to fall in November 2024, without injury, and was initially re-assessed December 10, 2024. Resident was subsequently re-assessed four more times between December 10, 2024, and March 20, 2025, after additional falls. Management had R1 medically evaluated by a mobile physician who visited the facility two to three times weekly checking on residents including R1. The physician adjusted R1’s medications and staff continued to monitor them for changes. Continued on LIC 9099C DATED 05/08/2026

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BELMONT VILLAGE ALISO VIEJO	FACILITY NUMBER: 306005563
	VISIT DATE: 05/08/2026

NARRATIVE

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During R1’s residency at the facility, they had approximately 14 falls that were reported to the Department which occurred during the evening and early hours. R1 was not diagnosed with sundowning, however, staff reported the resident was restless at night and had difficulty sleeping. On March 17, 2025, staff reported finding R1 in front of their apartment with a red and purple eye and blood around the nose. 911 was activated and the resident was transferred to the Hospital where they were diagnosed with a sustained closed blowout fracture of the right orbital floor; fracture of the L5 lumbar vertebrae; and fractures to rib and the left clavicle. R1 was discharged and returned to the facility same day with orders for follow-up appointments with primary care and orthopedic physicians. On March 26, 2025, at about 11:39 PM, R1 was found on the floor by a caregiver and 911 was activated. R1 was sent out to the hospital, and no additional injuries were noted. The resident was discharged from the hospital at about 6:30 AM and returned to the facility. The resident’s family was contacted and a companion from a Homecare Agency was hired to accompany R1 between 11 PM and 7AM for additional supervision. Five out of seven staff and Administrator confirmed R1 was provided with fall prevention tools including a bed alarm, floor mat and motion cameras in the room as well as a pendant and a bracelet for R1 to use if remembered. Administrator stated having multiple conversations with the resident’s family regarding a higher level of care, hiring a companion and the option of moving to a smaller environment. R1’s family confirmed the conversations.
The facility provided measures to alert staff if R1 had a fall, however, R1 still had 14 falls within a five-month period. While the facility implemented fall risk measures to alert staff when R1 had falls, measures implemented failed to ensure R1’s safety. R1 required additional supervision and a higher level of care to protect them from repeated falls. The facility was unable to mitigate R1’s falls with measures utilized and additional mitigation measures such as a full-time companion were not implemented. R1 was placed at a board and care on March 31, 2025, where R1 is reported to be doing well, and no falls have been reported. Based on the totality of evidence obtained, the Department has concluded that the facility failed to provide adequate care and supervision to a known fall-risk resident by not implementing sufficient reasonable safety measures or monitoring practices resulting in R1 sustaining an unwitnessed fall and injury.

The following is being cited per California Code of Regulations, Title 22. A Civil Penalty is pending determination by Community Care Licensing Division as per H&S Code 1569.49(f).

An exit interview was conducted with Administrator Anie Becker and a copy of this report was provided.
*This is an amended report.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/14/2026 03:11 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/13/2026 01:07 PM

Created By: Kimberly Lyman On 04/20/2026 at 10:27 AM

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
CCLD Regional Office, 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: 05/08/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/09/2026 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This req is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to provide an in-service on fall prevention and forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and record review, Licensee failed to ensure care and supervision was provided to R1. R1 had 14 falls within a five month period which poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Ortiz
NAME OF LICENSING PROGRAM MANAGER:

	Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC809 (FAS) - (06/04)

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