306005563-4-28-2022-22-AS-AORZ-CE3UJJ-20220503153734

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005563
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:15:31 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/14/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220214103038

FACILITY NAME:	BELMONT VILLAGE ALISO VIEJO		FACILITY NUMBER:	306005563
ADMINISTRATOR:	AYALA, ROSA		FACILITY TYPE:	740
ADDRESS:	300 FREEDOM LN		TELEPHONE:	(949) 643-1050
CITY:	ALISO VIEJO	STATE: CA	ZIP CODE:	92656
CAPACITY:	180	CENSUS: 97	DATE:	04/28/2022
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Rosa Ayala		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff mishandled resident's medication while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Ayala arrived during the visit.
During the course of the investigation, LPA interviewed Administrator Sullivan and staff as well as reviewed and obtained pertinent documentation such as Medication Administration Record and physician report. Regarding the allegation that staff mishandled resident's medication while in care, the investigation revealed the following: Resident 1 (R1) moved into the facility at approximately 2PM on 02/04/2022. R1 was found on the floor in the resident's room on the morning of 02/09/2022 with bruising and a laceration. R1 was sent out via 911 due to bruising. During the initial complaint visit, LPA was provided with a Medication Administration Record (MAR) indicating that R1 had received medications while at the facility. Upon further investigation, LPA was provided with a blank MAR from a witness that indicated R1 had not been given the medication while at the facility. During interviews conducted with staff it was CONT ON LIC 9099 DATED 04/28/2022.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220214103038

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/28/2022

NARRATIVE

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discovered that the MAR document had been falsified and the medication had not been administered. Interviews conducted with staff indicate R1's medications had been sent out to the pharmacy for re-packaging and there were no medications left at the facility to administer. Pharmacy re-packaging of medications is standard practice at the facility. Four out of five staff interviewed indicated being told by facility management to sign the document after the fact. R1 was part of the "Circle of Friends" group at the facility. This group is assisted out of their rooms to meals and activities daily by facility staff. Documents provided by facility indicate that resident was being escorted to meals and activities. Dietary documents show resident was provided meals. Door key records indicate facility staff was observing R1 every 2-3 hours during daytime hours. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director Ayala and a copy of this report was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220214103038

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CCR 87464(f)(4)	1 2 3 4 5 6 7	Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as... assistance with taking prescribed medications...This req is not being met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit a plan to ensure new residents are provided medication while re-packaging occurs at pharmacy and forward proof by POC due date.
	8 9 10 11 12 13 14	Per interviews conducted, Licensee failed to ensure medication assistance was provided to R1. R1 was at the facility for four days and did not receive medication. Physician report dated 01/10/2022 indicates R1 is unable to manage medications. This poses an immediate health ansd safety risk to residents in care.	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.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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