Belmont Village Aliso Viejo

Allegation investigated: Staff excluded resident's authorized person from making decisions regarding resident's care Staff retained resident at the facility without consent or court order

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as court documents. Regarding the allegations that Staff retained resident at the facility without consent or court order and Staff excluded resident's authorized person from making decisions regarding resident's care, the investigation revealed the following: R1 has Durable Power of Attorney (DPOA) paperwork dated July 6, 2021, designating three family members as agents of healthcare and financial decisions. The Department reviewed a Probate Settlement Agreement dated 06/10/2025 through the Superior Court of Orange County. Agreement indicates if R1 is unable to be safely maintained in the home, the resident will be moved to a memory care unit. The document indicates Resident 1 (R1) had been refusing caregivers in the home. Guardian ad Litem report dated 01/23/2026 indicated that the resident was unable to return home. CONTINUED ON LIC 9099 C DATED 05/26/2026 Unfounded The agreement was signed by all three agents, as a result R1 was moved into facility for care. Per communications provided by the facility, all three DPOAs are kept informed of R1’s ongoing care. Based on interviews conducted and record review, the allegations are deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility. Regarding the allegation that staff do not take precautions to mitigate the spread of illness in the facility: Private Care Companion 1 (CC) denies working at the facility with Covid or any other illness. LPA observed the facility to be clean and sanitary with infection prevention practices. Administrator denies being aware of any staff or companion working with Covid. LPA attempted to interview Resident 1 (R1) who refused to speak with LPA. During the facility annual conducted on February 19, 2026, LPA reviewed six staff files and confirmed facility staff have required training's on infection control. CC was hired privately by R1’s family and was therefore not subject to facility staff required training's. LPA toured the facility and observed the facility had ample Personal Protective Equipment (PPE) to meet residents needs in care. Regarding the allegation that staff did not seek medical treatment for resident in a timely manner, staff caused injury to resident in care, staff made inappropriate comments towards resident and staff yelled at resident: Review of facility progress notes show that medical attention was obtained for the resident on three different occasions between 09/02/2025-01/03/2026 for urinary tract infections, 09/25/2025 for redness on the lips, 09/20/2025 for antibiotic eye drops, 09/13/202 for low blood pressure, 07/17/2025 for swelling of the leg and ankle, and three occasions between 09/14/2025-10/16/2025 for falls without injury. Facility documentation indicates responsible party was notified. Three out of three staff, two out of two care companions and two out of three witnesses deny being aware of any allergic reactions or unreported injuries. Witness provided photos of bruising on the resident’s legs however LPA is unable to determine the incident and two out of two staff, two out of three witnesses and two out of two care companions deny the injury as well as witnessing any yelling, physical abuse or inappropriate language directed at resident. Resident 1 refused to speak with LPA regarding the allegations. During the facility annual conducted on February 19, 2026, LPA reviewed six staff files and confirmed facility staff have required personal rights training. Regarding the allegation staff interfered with resident's ability to make phone calls: LPA observed resident’s phone during visit to facility. Resident was sitting on phone and stated that it is where the resident likes to keep the phone. Resident confirmed preferring a cell phone as the resident can always keep it with her. LPA attempted to further interview resident however resident declined to continue to speak with LPA. Resident, staff, witnesses and care companions all confirm resident uses the phone when they wish and chooses who to talk to. CONTINUED ON LIC 9099C DATED 05/26/2026 Regarding the allegation unauthorized staff are providing care and supervision to resident: Per resident appraisal dated 01/13/2026, R1 is receiving assistance with activities of daily living including showering, dressing, grooming, toileting and escorting. Two out of two staff, two out of three witnesses and two out of two care companions confirm facility staff is providing the caregiving when the resident allows. Resident appraisal notes R1 is prone to refusing care. Care companions state accompanying resident for toileting but not providing actual toileting care. LPA observed the care companions are criminally cleared and associated to the facility. Regarding the allegation staff providing resident medication under false pretense: Facility caregivers indicate med techs provide all the medications. Two out of two care companions deny having anything to do with the resident’s medications and deny speaking to the resident about the medications. Two out of three witnesses and two out of two care companions deny any knowledge of care companions calling medications “Vitamins” and stated satisfaction with facility’s administration of medications. Family interactions regarding medications are outside the department’s prevue. Seroquel was ordered by the physician, and facility is required to follow the physician's orders. Regarding the allegation Staff did not follow reporting requirements: LPA observed incident reports submitted to the department regarding the resident including send outs to the hospital. Administrator and staff deny knowledge of any unreported injuries or allergic reactions. LPA did not observe any documentation regarding any unreported incidents in the progress notes. Three out of three witnesses stated W1 was the point person however, LPA reviewed documentation including emails showing all three DPOA’s were informed regarding R1’s care. Due to cognitive decline, LPA unable to interview residents in the memory care unit. Based on records reviewed and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, May 26, 2026 · control 22-AS-20260107132248

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA delivered an amended report from case management visit on 05/08/2026. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 14, 2026

Type of visit: Case Management - Deficiencies

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 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.the state’s words, verbatim · CDSS document, May 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 9, 2026

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: 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 ASSESSEDthe state’s words, verbatim · CDSS document, May 8, 2026

Plan of correction: Licensee agrees to provide an in-service on fall prevention and forward proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to Belmont Village. The purpose of today’s visit was to conduct the required 1 year inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 180 non-ambulatory residents of which 35 may be bedridden. Facility has an approved hospice waiver for 35 residents. There are 10 residents on hospice during today's visit. The facility has 147 apartments with 46 units for memory care. Administrator Rosa Ayala has an administrator certificate expiring on 10/23/2026. Upon entry, facility appears clean, safe and sanitary. LPAs Lyman and Mendivil along with Building Engineer John Lachey toured the facility at 9:40 AM. LPAs toured the physical plant, checked food service, reviewed files as well as reviewed medication administration. LPAs toured the memory care unit as well as assisted living. The main kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen and temperatures were in compliance. LPAs observed menus in the main dining room. Residents order off a menu and facility has daily specials for variety. There is an auxiliary kitchen and dining room in the memory care unit as well as a bistro in the assisted living. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPAs pulled emergency cords and staff response was immediate. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Ten resident bathrooms were tested for water temperature and water temperature measured between 113 and 118.4 degrees F in tested bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Smoke/carbon monoxide detectors are hardwired and facility has sprinklers. CONTINUED ON LIC 809C DATED 02/19/2026 LPAs observed documentation of last fire inspection dated 07/08/2025 conducted by West Coast Fire and Integration. Smoke detectors are monitored through an electronic monitoring system, alerting staff when there is any issue with a smoke detector. Fire extinguishers were fully charged. LPAs reviewed the emergency disaster plan as well as documentation of monthly fire drills with the last drill conducted on 01/30/2026. Facility is equipped with a generator. Facility provides daily activities in the form of exercise, games, and outings in the community. LPAs toured the outside grounds and observed a locked, alarmed pool as well as ample shaded seating for residents. Facility has a theater as well as a hair and nail salon. LPAs reviewed ten resident files and six staff files. Resident files reviewed contained required documentation including physician reports, admission agreements, and resident appraisals. Resident files reviewed contained required documentation including criminal background clearance, personnel record, required annual training, and health screen/TB. LPAs reviewed medication administration and storage. Medications are stored in locked medication carts. Medications appear to be administered per physician order. LPAs observed the first aid kit contained all required items. No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 19, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 02/04/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has been cleared. LPA observed medications are secured. Licensee has complied with the POC. Licensee has been advised to maintain all areas of facility in compliance. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 20, 2025

Allegation investigated: Staff are not trained properly on how to deal with dementia residents

Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias conducted an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff. Regarding the allegation that staff are not trained properly on how to deal with dementia residents, the investigation revealed the following: On 02/12/2024, Staff 1 (S1) had an altercation with a memory care resident. Resident 1 (R1) grabbed a duster from S1's cart and attempted to push the cart. Per interviews conducted, S1 reacted inappropriately and was subsequently terminated. LPA reviewed training record for S1 and the staff received Dementia training in 05/23/2023 and 12/14/2023 even though she was employed as a housekeeper and not a caregiver. Based on interviews conducted and record review, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility. Unfoundedthe state’s words, verbatim · CDSS document, Feb 4, 2025 · control 22-AS-20240212153740

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias made an unannounced visit to conduct the required annual inspection. LPAs met with Executive Director (ED) Rosa Ayala and explained the reason for the visit. The facility is a three story building which consist of 30 units on the first floor reserved for memory care residents, and 16 additional units on the second floor for memory care residents. The capacity of the facility is 180 non-ambulatory and a hospice waiver for thirty five and bed ridden waiver for thirty five. There are currently a total of 134 residents, 46 of them are in memory care, and 14 on hospice. Rosa Ayala's Administrator's Certificate is in process of renewal as of 12/23/24. LPAs observed the PUB 475 poster (See Something, Say Something Poster) posted by the resident mail box. The PUB 475 poster posted is 20" X 26." LPAs observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPAs observed the emergency food and water. LPAs and ED toured resident rooms on three floors of the facilities. LPAs and ED toured the resident rooms in memory care unit area. LPAs inspected twelve resident rooms. All resident rooms had the required furnishings. All resident bathrooms were clean and operational. At 9:58am, one out of twelve resident rooms observed had PRNs in the bathroom. LPAs tested the emergency alarms and observed the staff came promptly when alerted. The hot water in the twelve resident rooms inspected measured 112.4 degrees Fahrenheit to 117.3 degrees Fahrenheit. LPAs observed residents participating in exercises in the activities room in the memory care area. There is fitness room and activities room for all residents. There is an outdoor courtyard for residents to sit outside. In the outside area there is a garden for residents to plant things. There is a pool area secured with a gate. Residents can utilize the pool as long as they are accompany with a staff who is water safety certified or a family member. In the summer they have water aerobics. There are fire extinguishers on every floor and all fire extinguishers are fully charged. LPAs observed emergency evacuation chairs in each stairwell. The last emergency fire drill was conducted on 1/29/25. The fire safety system is inspected annual every year by an outside agency, The last inspection was 8/30/24. LPAs reviewed twelve resident files with no discrepancies. All resident files had the required documents. Continued on LIC-809C 2/4/2025 LPAs reviewed five staff files with no discrepancies observed. All staff files reviewed had current CPR/First Aid training. At around 2:30 PM, LPAs inspected medication and medication administration records (MAR) for selected residents. No discrepancies observed. LPAs observed medications are kept secured in a medication cart that is locked in a medication room. LPAs observed the first aid kits to have all the required components and a first aid book at hand. LPAs interviewed staff and residents. No obstacles or hazards were noted inside or outside of the facility. Based on the observations made during today's visit, 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.the state’s words, verbatim · CDSS document, Feb 4, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide an appropriate sleeping arrangement for a resident Staff do not provide adequate care and supervision to a resident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA interviewed staff and resident as well as reviewed and obtained pertinent documentation such as home health documentation. Regarding the allegations that staff do not provide adequate care and supervision to a resident and staff did not provide an appropriate sleeping arrangement for a resident, the investigation revealed the following: Resident 1 (R1) was seen by home health for dermatitis for approximately two months and was discharged from home health on 01/24/2024. Resident has a primary care physician in the San Diego area and stated requesting a physician visit from the Wellness Center in an attempt to find a physician nearby. Resident stated having some swelling on the legs as the resident is prone to Dermatitis. LPA observed resident wearing compression socks and resident stated the socks are worn daily as directed. CONTINUED ON LIC 9099C DATED 05/06/2024 Unsubstantiated Resident shares a room with the resident's wife. Resident stated that upon admission, resident shared a queen bed with wife in the facility apartment. A few months later the resident's wife needed a hospital bed and the resident donated the queen bed to charity without informing the facility. Resident indicated pressure from facility to utilize another bed and resident refused. Last week, resident obtained a bed from the facility and LPA observed the bed in the resident's room. Per physician report dated 09/27/2023, Resident is independent and making own decisions. Based on record review and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, May 6, 2024 · control 22-AS-20240501161913

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Michael Tea made an unannounced visit to conduct the required annual inspection. LPAs met with Executive Director (ED) Rosa Ayala and explained the reason for the visit. The facility is a three story building which consist of 30 units on the first floor reserved for memory care residents, and 16 additional units on the second floor for memory care residents. The capacity of the facility is 180 non-ambulatory and a hospice waiver for thirty five and bed ridden waiver for thirty five. There are currently a total of 117 residents, forty two of them are in memory care, and eleven on hospice. Rosa Ayala's Administrator's Certificate expires on October 23, 2024. LPAs observed the PUB 475 poster (See Something, Say Something Poster) posted by the resident mail box. The PUB 475 poster posted is 20" X 26." Around 9:49 AM, LPAs and ED Ayala toured the facility. LPAs observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPAs and ED toured resident rooms on three floors of the facilities. LPAs and ED toured the resident rooms in memory care unit area. LPAs inspected twelve resident rooms. All resident rooms had the required furnishings. All resident bathrooms were clean and operational. LPAs tested the emergency pendants and observed the staff came promptly when alerted. The hot water in the twelve resident rooms inspected measured 112 degrees Fahrenheit to 118.2 degrees Fahrenheit. LPAs observed residents participating in exercises in the activities room in the memory care area. There is fitness room and activities room for all residents. There is an outdoor courtyard for residents to sit outside. In the outside area there is a garden for residents to plant things. Also there is a pool area with a gate. Residents can utilize the pool as long as they are accompany with a staff who is water safety certified or a family member. In the summer they have water aerobics. There are fire extinguishers on every floor and all fire extinguishers are fully charged. LPAs observed emergency evacuation chairs in each stairwell. The last emergency fire drill was conducted on March 13, 2024. The fire safety system is inspected annual every year by an outside agency, the last inspection was 9/19/23. Around 11:10 AM after the facility tour, LPAs reviewed twelve resident files with no discrepancies. All resident files had the required documents. Afterwards LPAs reviewed ten staff files with no discrepancies observed. Annual Report cont on LIC-809C All staff files reviewed had current CPR/First Aid training. At around 2:30 PM, LPAs inspected medication and medication administration records (MAR) for selected residents. No discrepancies observed. LPAs observed medications are kept secured in a medication cart that is locked in a medication room. LPAs observed the first aid kits to have all the required components and a first aid book at hand. LPAs interviewed staff and residents. No obstacles or hazards were noted inside or outside of the facility. Based on the observations made during today's visit, no deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report providedthe state’s words, verbatim · CDSS document, Apr 30, 2024

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff failed to provide care and supervision which resulted in resident sustaining injuries during elopement

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility and explained the reason for the visit. During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including Physician Report, Resident Service Plan, Orange County Sheriff’s Report, Orange County Death Certificate and Mission Hospital Medical Records. The purpose of today’s visit is to follow up on an investigation conducted by the Department regarding the above allegation. The investigation conducted revealed the following: Resident 1 (R1) was admitted to the facility on April 30, 2023. Physician report dated April 25, 2023, notes that R1 had a diagnosis of Dementia. On July 09, 2023, R1 sustained a fall from their bedroom window located on the second floor of the facility. Surveillance video obtained from Aliso Ridge Behavior Health, which is located across the facility parking lot, captured R1’s attempted elopement. CONTINUED ON LIC 9099C DATED 03/20/2024 Unsubstantiated Per the video obtained, R1 can be seen knocking the screen out of the window and climbing halfway out the window. R1 then climbed out onto the small ledge beneath the window and turned around to jump to the ground. At approximately 6:41 PM cameras observed a shadow seen falling out the side of the building. At approximately 6:53 PM a staff member found R1 lying on the sidewalk below their bedroom window. Resident records obtained did not note R1 had a history of suicidal ideation. Interviews with five of seven staff reported R1 had a history of wandering and attempted elopement. Orange County Coroner Report lists R1’s cause of death as Hemopneumothorax, Rib Fracture and Traumatic fall. Per facility policy, windows in the facility memory care are fixed to open no more than eight inches to allow fresh air into the rooms for residents. All exit leading doors are equipped with auditory alarms and delayed egress to alert staff of attempted elopements. Although R1 sustained a traumatic fall resulting in their death, a review of records obtained and interviews conducted determined that R1’s injuries were not sustained as a result of neglect by the facility staff. Evidence obtained indicates more than likely that R1 was unaware of the consequences of their actions and likely fell while attempting to leave the facility. Therefore, based on interviews conducted and documents reviewed, the allegation that staff failed to provide care and supervision which resulted in resident sustaining injuries during elopement is deemed Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report and confidential names list was left at the facility.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 22-AS-20230711102555

Allegation investigated: -Facility failed to provide resident's records to authorized representative

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the investigation, LPA interviewed Executive Director as well as reviewed and obtained documentation such as request letter for documents. Regarding the allegation that facility failed to provide resident's records to authorized representative, the investigation revealed the following: Facility received a request for Resident 1's (R1) records dated 11/16/2023 and received via Federal Express 11/17/2023. Facility indicated working on submitting records as of today, 11/29/2023 but that the records had not been submitted to date. Based on records reviewed and interviews conducted, 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. Substantiatedthe state’s words, verbatim · CDSS document, Nov 29, 2023 · control 22-AS-20231121140704

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(21) · Plan of correction due date: Dec 1, 2023

Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days..This req is not being met as evidenced by: Based on records reviewed, Licensee failed to submit requested documents to resident's agent. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 29, 2023

Plan of correction: Licensee to submit requested records to resident's agent and forward proof to LPA by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 11/07/2023. LPA were greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87464(f)(4) pertaining to Basic Services has been cleared. Licensee provided proof of correction. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87464(f)(1) pertaining to Basic Services has been cleared. Licensee provided proof of correction. Licensee has complied with the POC. Licensee has been advised to maintain all areas of facility in compliance. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 29, 2023

Allegation investigated: Staff did not give medications timely Oxygen was not kept on resident according to physicians orders

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as physician report and hospice notes. Regarding the allegations that oxygen was not kept on resident according to physicians orders and staff did not give medications timely, the investigation revealed the following: Resident 1 (R1) admitted into hospice care on 12/02/2021. Hospice orders dated 12/02/2021 indicated an order for oxygen, 2 liters, given continuously and 2-5 liters for shortness of breath. Two out of two staff stated that the resident was agitated and would pull the canula out. However, hospice notes dated 01/14/2022 and 01/19/2022 indicated the oxygen tank was turned off when hospice nurse arrived. Hospice notes indicated that the resident's breathing declined rapidly without the use of oxygen. Additional hospice documentation indicated caregivers were not advising facility when the oxygen tank had run out. CONTINUED ON LIC 9099C DATED 11/07/2023 Substantiated R1 was initially prescribed Morphine .25 mg/ml as needed for pain. Per hospice notes dated 01/05/2022 and 01/07/2022, resident is unable to make needs known and unable to verbalize pain. Facility LVN's were the ones providing the Morphine to the resident as needed. Witness indicates expressing to staff that R1 was unable to verbalize pain and would request R1 be given the medication. Resident could be observed to be in pain by moaning and grimacing. Hospice prescribed a new order of Morphine in the morning on 01/26/2022 for Morphine 0.5 mg/ml, three times daily, routine. Per hospice notes, nurse arrived in the evening of 01/26/2022 to ensure medication was being administered. Resident is observed to be in pain with no Morphine administered. Hospice notes stated that Staff 1 (S1) indicated the staff had not received an order even as there was an order for Morphine as needed, still standing. Hospice nurse administered the medication to the resident. Hospice nurse attempted to educate S1 regarding medication orders and the purpose of hospice care and the staff was "Not receptive." The next day, 01/27/2022, Hospice nurse arrived to the facility to discover facility staff had failed to administer routine or as needed Morphine, again, despite education and medication orders. Hospice nurse administered the medication during the visit and resident was put on comfort measures that day. Resident passed away on 01/29/2022. Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore the above allegations are 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.the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 22-AS-20220223091921

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(F)(4) · Plan of correction due date: Nov 8, 2023

Basic services shall at a minimum include: Personal assistance and care as needed by the resident..., with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications..This req is not being met as evidenced by: Based on records reviewed, Licensee failed to ensure R1 was being assisted with medication assistance. Per hospice documentation, resident was not receiving prescribed pain management at end of life. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2023

Plan of correction: Licensee to provide an in-service inconjunction with hospice regarding medication administration and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 8, 2023

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 requirement is not being met as evidenced by: Based on record review, Licensee failed to ensure care was being provided to R1. Per hospice documentation, R1's oxygen was turned off on two different occasions when hospice arrived. R1 was prescribed continuous oxygen. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2023

Plan of correction: Licensee to provide an in-service on oxygen administration and forward proof to LPA by POC due date.

Allegation investigated: Staff did not provide adequate food service

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on 09/05/23. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Rosa Ayala. LPA explained the reason for the visit. This agency has investigated the complaint alleging that staff did not provide adequate food service. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Three of ten individuals interviewed corroborated the allegation. During the investigation LPA reviewed documents including the Belmont Village Aliso Viejo Weekly Menu dated 09/07/23 through 09/20/23. Per Belmont Village Aliso Viejo Weekly Menu residents have multiple options to choose from for breakfast, lunch and dinner. During the interviews with residents it was reported that staff do not bring the correct food order. Per Resident 1 (R1) the kitchen staff are very attentive and provide excellent food service. Continued on LIC9099-C... Unsubstantiated During interviews conducted with Staff 1 (S1) it was reported that the kitchen has not received complaints regarding incorrect food orders and when there has been a complaint, it has come from a resident with cognitive impairment. Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with ED Ayala, and a copy of this report was provided to the facility. six minutes and fifty-four seconds. Per Resident 1 (R1) staff are helpful, do their best and assist in a reasonable time. Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. LPA Ramirez conducted an exit interview with ED Ayala, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 22-AS-20230905151814