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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005563
Report Date: 06/02/2022
Date Signed: 06/02/2022 03:00:41 PM


Document Has Been Signed on 06/02/2022 03:00 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: 99DATE:
06/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Rosa AyalaTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an SOC 341 received by Community Care Licensing on 05/30/2022. LPA met with Executive Director Rosa Ayala and explained the reason for the visit.

SOC 341 dated 05/30/2022 indicated Staff 1 (S1) was overheard by a visitor making inappropriate statements to Resident 1 (R1) while resident was shouting. Facility staff notified and resident was assessed to have no injuries. S1 was immediately put off schedule while an investigation was conducted. Facility completed an investigation and S1 was brought back to work on 06/01/2022. Facility has begun to conduct an eight step training program for Dementia care.

During the visit, LPA toured the memory care unit and interviewed staff. Four out of four staff interviewed deny witnessing any abuse or inappropriate behavior towards residents. All staff indicated challenging behaviors by R1 but deny any abusive behavior from staff. R1's physician report dated 09/28/2021 indicates a diagnosis of Alzheimer's Disease/ Dementia. LPA reviewed S1's training records during the visit. S1 is current on training including Dementia Care, Personal Rights, and Reporting Requirements.



No deficiencies noted during today's visit. Exit Interview 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: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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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