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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005563
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:16:42 PM


Document Has Been Signed on 04/28/2022 02:16 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: 97DATE:
04/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Rosa AyalaTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit in conjunction with complaint visit 22-AS-20220214103038 . LPA met with Administrator Rosa Ayala and explained the reason for the visit.

During the complaint investigation, LPA interviewed staff regarding the mismanagement of Resident 1's (R1) medication. LPA received two copies of Medication Administration Record (MAR) during the investigation, one from a witness and one from the facility. The copy received from facility was signed by staff and obtained on 02/15/2022. The copy provided from a witness was obtained on 02/11/2022. Further investigation revealed the document had been falsified between 02/11/2022 and 02/15/2022. Four out of five staff interviewed indicate facility management requested staff to sign the MAR even though the medication had not been administered to the resident.


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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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Document Has Been Signed on 04/28/2022 02:16 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
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: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited

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The department may deny an application for a license or may suspend or revoke a license...(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This poses an immediate health and safety risk to residents in care.

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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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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